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AR ., <br /> e` SAN JOAQUIN LOCAL H, AL*TH DISTRICT } F � ..., � �, Y ��� <br /> FOV OFFIGt USEI 1601 M. Raselton Ave., Stockton, Calif. <br /> Telephones (209) 4"-6761 <br /> APPLICATION 101 Whet. COliMUCTION OR PMPMUUT . Perin no. y 2 0 v <br /> . a <br /> THIS PERWV ZZXPi1tRs_1_YEAA Mm DATE I6SOSD, Mata 2s+rwd* ! s <br /> 77 <br /> (C mplete In Triplicate) "; g s -ZI <br /> APPHration to hereby made eta`thea San Jow&In Local Health tliatrict,,for a pornis;to 'Cfl>MtrI1Ct s <br /> and/orim t4al the work herein described• This applications In sad&,in a nVUssstr'"orith;�;Joie <br /> County► M- Il ee leo. 1862 and tha and validations o!`the°San Joaquin+.Loth►]. Health �iiat4,{ <br /> /3 S/ �' <br /> Jft manS/tACA't'1Od inL ua `*"Ct' 8Gr8 .*ACT <br /> • .Y, . a � R <br /> P A kava z. "Poona 9A b" ;, a <br /> Wtgx IMIIU III IN^ y�M <br /> ` l+tea ,.�/•-V J�r et ' License'�! ,(ate Phone 1 ' <br /> •T"Rft= (Check)a NEW VELL DUPEN: /7 - RSOONDITION '!7 DESTRUCTION ., <br /> X�g � Ptd INSTALLATIOl4 1st RuAIR L,7 Pvw,� '4� .ti <br /> y � x <br /> ...F. �, <br /> other L7 - <br /> ��t' <br /> Tfi IiEARQBtt gHPTIC TANK40 SBetBA.LINES PIT'.PRIVY <br /> Smum DISPWAL nmD� CBSSPOOL/SUVAG8 1'IT OTttBR ", s <br /> ...I......... h ra�rr • i <br /> a; USE TYPE 01F WELL CONSTRtiCTIOp SP ITICATXG'hi�f <br /> Cable 'cool Die. Of Well Excavation <br /> trilled rife. .�..L....,,.r...�,r..— +. <br /> ltit/t►Tivaee. of Ball Catling <br /> ,��.Doii iitit/p ►lac Driren Gauges of Casing ��I,?r^ %A <br /> Irc ltieee Crewel Pack Depth of Grout 5"1 r-O I <br /> Mary Type of Groot <br /> =Y 8tber' Other Infarmation <br /> whip �L�' om1:-1 Ccaaetlactor ' pis.• <br /> .--.F...�lwwfWl.o... , <br /> G 4` <br /> �Pii!!P t L7 State stork Done <br /> AIl; L7 6`. <br /> PUS State York Done <br /> � <br /> eOF W LLt W*ll Mamtesr Approximate Depth 0" _Describe Material and Procedure l <br /> y <br /> I hereby agree to complj rfth all lave reg-.e tiema o Cho ban =40 n tical tai D atr et i <br /> and the Stant of California pertaining to or reg+,latb* well tonstruetinn• <br /> aftar-COW totion of my work on a nese well. I trill furnish the Flan Joaquin Lotal Health Dietitiat'a#t. <br /> w= VULLM WWORT of the wall. amt notify thou before putting the V611 is use• ;r The aberre `1I <br /> inform stim is true to the beat of any kmwlodga and ballet. <br /> SIGH .�f ��. TI= <br /> rcaa –CA ON v�.�r SID <br /> A"Tp i ►n0W ACCO- lay. <br /> ADDITIONAL WMEM: - I '6`,r <br /> rRASlt 11 GROUT INSPr TION PMA$E RUM 83�EC7IOft <br /> By DATINSPECT►Olt 8Y DATE <br /> I s�, CALL FOR A CROUT INSPECTION RRIOR TO CROMINO AND FINAL XXSPRCION. <br /> E S 1426 7i 72 1!1 <br /> I �,rx..—...,.—.,.� � .w— ,...;+ea..r.sf-�x +�e�x- � t�' �'q�yr•rr I <br /> L._ --��3- .3`11'..."-.�'N.�'1_�5:.-, ::;d.ry_a'_,.d • .':.fk:� r:_RiK. _._._.-.�--� �-ID.°•� _ _ _.____��. _ . ._ -_. .� - - _ � I <br />