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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> I <br /> JOB ADDRESS/LOCATIONTVAJ-I'Allffiv� RdCENSUS TRACT <br /> i <br /> Owners Namete Phone 68_ 2a <br /> Address N th wa - Rd Lodi CA City f Lodi <br /> Contractor's Name License # Phone <br /> til <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /% RECONDITION / / DESTRUCTION /Ta' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT [7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <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 /> I <br /> Disposal 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 Depths <br /> ® Describe Material and Procedure ,,GP <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 />?RIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY _ <br /> - <br /> APPLICATION ACCEPTED BY . DATE 9 <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r` <br /> 1/77 <br />