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<br /> 'COPY ,
<br /> .)Ag11[.N LOCAL IVALTII:T7SSTV
<br /> FOR OFr1G>r L'SE Il:tzelton Ave: , Stockton G�lif .
<br /> I'::i.ephone, {20
<br /> 9) 466678
<br /> FuR WrIA, CONSTRUCTION OR PERMIT
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<br /> EXIiIRES 1 YtAR FROM DATE ISSUED Dnt(� Irisucd _ `4
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<br /> ApplicAtlon 'ii hereby tnndl. t .: San .Joaquin Local Health District for a per;nit to construct
<br /> and/or install the work [.cre •.r rlr�,?crlbed. This application la made in compliance with San Joaquin ;
<br /> County Ordinance No. 1862 arxi rules and Regulations of the San Joaquin Local fie-kith District.
<br /> JOB ADDRESS/LOCATION `-�" C� ', %J f'�%•� 'r`� CENSUS TRACT
<br /> Oyncr` ,�nc-� �� ,'^'�_� t• _� ! �� i`�. PhwnA .��' ..�'-�"Z A:• �} �r{� v i
<br /> Address .f1�1 e--el /�.��". / F f--�.�f� City r
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<br /> Contractor's Natne' -� ` -_1 �� �'/�� tf�•f License i � %'Phoney
<br /> TYPE OF WORK (Check) ; ni-ty ,DEEPEN /-7 RECONDITION DESTRUCTION /-7 Nk
<br /> 1'1.411' N,:` i Al LAT _] 7PUMP REPAIR L?—PUMP RR.FLAWII:NT
<br /> DLSTAN4TW1O
<br /> NEARES'i:• SF.PTI.t S1rWERsr.�, . .q....�� ~ PIT PRIVYI� � 'f
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<br /> .,.r. yu.�it. 6zi11�:Fy`� 6�. IT #. ., (3Tilt R; I a, �
<br /> ' �' ! I �'•.i 'T+�l IA. .,j -f.r F��..� 'J. UV $�I� is A s
<br /> _ PROFf RT`.' ' ' 3'RIVA',�'> ?Mfil` LL; ' i °I111LIC DOMESTIC WFf 1
<br /> INTENDED USE ; '"'1'' ,� ' tr`LLL ti 1 31'f k r , I,t3 'CONSTRUCT:ION SPECIc iCATIi1N5.'�i , lir tt! 6 I i
<br /> Lt7�lluwt:>^tnl 0,ibin Tool #MIN,''0'� Aacjj ill excavation
<br /> µ �" .Cibmrgt is/private tir+.lJed <�„;'•DiIt6 +bf<.iitell Casing
<br /> Domes Wic/public _� 1 ; lven "t,s ill"Gt ugo°`�of,Cnsi.ag
<br /> Irrigation nivel Pack �+ pthpo IGresut Seal
<br /> CAthodic Protection _ ?rotary p4tof :Grout
<br /> Disposal - Other '�;Otiie�t.Yttformation
<br /> Geaphysicnl `Suifare, Seal: Installed H _ _ _ " tjo
<br /> 111MP INSTALLATION.".;", ' fnnr, - :. 'f �.. ,- z
<br /> PUMP REPLAC1;MrNTjf `, l'I :.�i i•in iC Done_//f � r�'-+ iLi'.r�_7.. Lr 7 l RIJt
<br /> 1t'PAIR
<br /> ''ot'IC E1A I:Ff� • v st r° .wm.,. -,. ....., .. - ,� •yl...... a '"' i
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<br /> . _ t 4O ' 1 'j]?STt1 WApproxir_�tr Xr ,ll+ y
<br /> and Protedur deur y _ _ _
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<br /> T lrr�t'rsl)y npt('�� lr� curr,ply 1,. f ,a irxi rc'gu et3+16tta q ths ins,Joaquin l;pct►i Hr..rltlr District x { ;
<br /> and the Stnte n[ CAJ,ffor.•,Iii I•s'ri to at regul'at'in��ut?ll construction. Wltl- zi 121FFEEN DAYS �
<br /> of ter complct.i ot`s of: my wart: 'rr t .i11W willl., I will tfurSan J6aquin Local Itc-il t:h DS.,,%tritt a
<br /> nRILI.I RS FrV.CRT o-F t til• h 1 1113 notify them 'before,puttln'g the well, .in title, . Th- ntinve
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<br /> in3=ormnl' lkrtowledRe and,-belief. i Wit,?- CALL FOR A ('3'RDUT TN1;j'I-CT10N i
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<br /> j � T"{,T X,t �.a.�.....�...«a..:�.. - a _ .. . ...�..:....
<br /> 3 itfiw!'-.,UT PLAN .ON REV ER51? iiW
<br /> F(.'q DF.PART.MENT USE ONLYt
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