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irk <br /> t • . ; SAN JOAQUIN LOCAL HEALTH DISTRICTS <br /> F0 OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> r. Telephone: (209) 466-6781 <br /> j APPLICATION FOR WELL- CONSTRUCTION OR PUMP PERMIT Permit No. 77- <br /> THIS <br /> 7THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7—lS 77 <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 2101 TurnerJRoad - Weil 7 CENSUS TRACT 32250 <br /> � <br /> Owner's Name City f Lodi Phone 368-0641 <br />. _� . .o - ... ,.„—. <br /> Address 221 W. Pine It City Lotti <br /> Contractor's Name --- I License # - Phone ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN%/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /- / ; PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1341 PIT PRIVY _ <br /> SEWAGEiDISPOSAL�.FIELD CESSPOOL/SEEPAGE PIT _-- OTHER Storm Drain-44` <br /> PROPERTY LINE 35 PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable T6ol Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> X Domestic/public Driven Gauge of Casing <br />` Irrigation. -Gravel Pack Depth of Grout Seal <br /> Cathodic Protection L Rotary Type of Grout \ <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 /> 1 <br /> PUMP -REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r � <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 />'E after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o he well and notify them before putting the.-well in use. The above <br /> information is true to te b t of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING FIN INSPECTION. <br /> SIGNED TITLE Public Works Director <br /> D W 'L T PLAN 'ON REVERSE SIDE) t : '' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1--li <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/F AL INSPECTION <br /> INSPECTION BY �� DATE - INSPECTION BYe-, DATE 11,21 <br /> c <br /> A*/� <br /> E H 1426 Rev. 1-74 .. �, <br />