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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSOFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. /�� <br /> Telephone: (209) 466-6781 /7 "5`// <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ! / _7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION mile E. of Lower Sacto. Rd. on S. side of ArmstronitENSUS TRACT <br /> Owner's Name J. R. Lauchland Phone 369 4653 <br /> Address 520 S. Mills City Lodi <br /> Contractor's Name W. G. Noack Inc. San Joaquin Pump Co. License # 200 794 Phone 466 0696 <br /> TYPE OF WORK (Check): NEW WELL FT DEEPEN/7 RECONDITION (7 DESTRUCTION r7 <br /> PUMP INSTALLATION ?"'J PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /� _.._ <br /> DISTANCE TO NEAREST: SEPTIC TANK90 ft. SEWER LINES • PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT : _OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 10 TUCIT <br /> ** Domestic/private Drilled Dia. of Well Casing 6 inch <br /> Domestic/public Driven Gauge of Casing .log <br /> Irrigation Gravel Pack Depth of Grout Seal 50 f't. CP <br /> Cathodic Protection — Rotary Type of Grout Cement. '�- <br /> Disposal Other Other Information (� <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor San Joaquin Pump Cow, Lodi <br /> Type of Pump Submersible R.P. 2 <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP .REPAIR: L7 State Work Done ---- _ <br /> .DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well in use.. The above <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND AFINAL INSPECrION. <br /> SIGNEDYAL a.P --V TITLE ai:d_1� <br /> (DRAW PLOT PLAN ON REVERSE SIDLrf <br /> FO ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B . C, S - DATE Ad <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4V.4 DATE -1Y O74" <br /> E H 1426 Rev. 1-74 1-74 2M <br />