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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephones (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,25 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a--3-, — <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 /> .TOB ADDRESS/LOCATION 345 E* Taylor Rd4 CENSUS TRACT ' <br /> Owner's Name Ed. .MeierPhone 36$ 1360 i <br /> Address 345 E.. Taylor Rd. City ' Lodi <br /> t <br /> Contractor's Name 11. G. Noack Inc. License #200794, Phone .466 0696 ,, . <br /> TYPE OF WORK (Check): NEW WELL `A*7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> ,DISTANCE TO NEAREST: SEPTIC TANK 87 f't. SEWER LINES 92 ft* 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 inch j <br /> *** Domestic/private Drilled Dia. of Well Casing 6 inch <br /> Domestic/public Driven Gauge of Casing 4109 <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ft. <br /> Cathodic Protection *'�'� Rotary Type of Grout Cement <br /> Disposal ...G. - 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 /> 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'-Joaquizi 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, -1 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-af. my. knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TOAGROPTI96AND A FINAL INSPECTION. <br /> SIGNED �.�e� .c;�. TITLE S a,le sm= <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED Y `y �. DATE <br /> ADDITIONAL COMMENTS: <br /> . .... . ...PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY Gl_ DATE INSPECTION. BY // DATE //E/� <br />