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Ai <br /> SAN JOAQU•IN LOCAL HEALTH. DISTRICT <br /> 0 OFFI:SE USE: 1601 E. Hazelton Ave., 'Stockton, Calif. <br /> I Telephone : ' (200) • 466-6781 <br /> APPLICATION FOR WELL CONSTRUCT16N OR PUMP PERMIT Permit No. 77 a/ <br /> THIS PERMIT EXPIRES 1 YEA_R�FROM DATE ISSUED Date Issued X77 <br /> (Complete In Triplicate) <br /> Application is hereby'made to the San Joaquin Local Health District`fot 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 215 1Z2 S. School St. - Weil 3 CENSUS TRACT 32250 <br /> Owner's Name ' City-of Lod i Phone 3 -0641 <br /> Address 221 W. Pine St. City LadL <br /> Contractor's Name --- <br /> License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION / 7�-6ESTRUCTION /-7 <br /> PUMP INSTALLATION '/ PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other /- / <br /> DISTANCE TO NEAREST: SEPTIC TANK --- SEWER LINES` 22' PIT PRIVY --- <br /> SEWAGEDISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT --- OTHER Storm Drain-5' <br /> PROPERTY LINE C PRIVATE DOMESTIC WELL - "' PUBLIC DOMESTIC WELL --- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing � { <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> i <br /> DESTRUCTION 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 -"j <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, T will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of he well and notify -them before putting the. well in use. The above <br /> informat' n is true to t t of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTI D A INb NSPECTION. <br /> SIGNED TITLE Public Works Director <br /> DRAW PZ T PLAN REVERSE SIDE) i; ,: <br /> PHASE I1\j <br /> FOR DEPARTMENT USE ONLY <br /> � 7 <br /> APPLICATION ACCEPTED BY y DATE 7/,j <br /> ADDITIONAL COMMENTS: I - - <br /> PHASE II GROUT INSPECTION PHASE I/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE . - <br /> fTV- <br /> E H 1426 Rev. 1-,74 � � 3/76 2M <br />