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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> ,?01a OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_2_—_&3_7 <br /> THIS PERMIT EXPIRES 1 YEAR°FROM DATE ISSUED Date Issued 77 <br /> (Complete In Triplicate) pcFC/_ r2a <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 F <br /> County=Ordinance No. 1862 -and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA ' Highway. 2:.@ CC_T tracks - Well 1 1 CENSUS TRACT 32250 <br /> Owner's Name City of Lodi Phone 368-0641 <br /> Address 221 W. Pine St. City Lodi <br /> 3 <br /> Contractor's Name License # Phone --- <br /> if <br /> r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTLATION '/ / PUMP REPAIR '/ / PUMP REPLACEMENT IX <br /> AL1 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK --- SEWER, LINES , PIT 'PRIVY --- <br /> SEWAGE DISPOS 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 /> _X Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout j <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: /7/ State Work Done <br /> DESTRUCTION OF .WELL:' Well Diameter J.. 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 the well and notify them before putting the .well in use. The above <br /> information is true <br /> hest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ' V0FINV <br /> ROUT G INSPECTION. <br /> SIGNED TITLE Public Works Director <br /> Jack L. Rons o D W i'L T PLAN 'ON REVERSE SIDE) See att6ched's eet <br /> FOR/DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECrfIOH,, PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> F. H IA26 RPv_ 1-74 <br />