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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 Telephone: (209) •466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7-] �3 Jo," <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-1_.�'-7 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 358 S6ady Acres Drive - Well 9 CENSUS TRACT -32250 <br /> Owner's Name City of Lodi �T Phone 368-0641 <br /> Address 221 W. Pine St. I City Lodi <br /> Contractor's Name --` License # Phone <br /> l <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /)C <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK --- SEWER LINES 50' PIT PRIVY <br /> --- <br /> SEWAGE- DISPOSAL FIELD ___. CESSPOOL/SEEPAGE PIT --- OTHER Storm Drain 10' <br /> PROPERTY•LINEI6'PRIVATE DOMESTIC WELL --- PUBLIC DOMESTIC WELL -- <br /> INTENDED -USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A Cable -Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing kill <br /> X Domestic/public � t Driven Gauge of Casing pe <br /> Irrigation Gravel Pack . Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout _ <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / IState Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ . Approximate Depth ^� <br /> Describe Material and Procedure <br /> I hereby agree to coamply 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 ak' <br /> WELL DRILLERS REPORT ofa well and notify them before putting the..well in use. The .above ` <br /> informatio is tr e o h ,be of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TIN NAL SPECTION. <br /> SIGNED TITLE Public Works Director <br /> ac Rons o DRAW- P�: T PLAN `ON REVERSE SIDE See attached sheet ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE-� J `� <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTI PHASE III FI INSPECTION �J <br /> INSPECTION BY DATE INSPECTION BY DATE ,2 -7I-l4 <br /> ' 3/76 2M <br />� E H 1426 Rev. 1-74 o <br />