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i <br /> f- SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 1/4/0/v <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 /> JOB ADDRESS/LOCATION 114 N. _Main St. - Well 4 CENSUS TRACT 32250 <br /> Owner's Name City of Phone 368-0641 <br /> Address 221 W. pine St. City Lodi <br /> Contractor's Name License # - Phone ' " -- <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /X <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK --- SEWER LINES 80' PIT PRIVY --- <br /> SEWAGE DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT --- OTHER Storm Drain-5' i <br /> PROPERTY LINE -Z 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 /> �X _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal, <br /> Cathodic Protection 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 /> PUMP ,REPAIR: / / State Work Done <br /> AES•TRUCTION 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 <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 /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE Public orks Dire for <br /> DRAW POT PLAN REVERSE SIDE 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �+ / <br /> APPLICATION ACCEPTED BY c- DATE <br /> 'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />