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of Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application J FOR OFFICE USE' APPLICATION .D (For Non-Transferable.Revocable,Suspendable) PUi111P&VJFt L ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY ApplicetmishereGyrnadetotheSanJoaquinLocalHealthDistrictforaPe"nit10Lo'istructand•urn:;tauthr.v„-,rknereinneserrbee Ih s application is X made in compliance wit'i San Joaquin County Ordinance No 1862 and trt, rti:as and ref7Ulation5 Of the San Joaquin Local Hearth District Exact Site Address 1675- Milgeo Rd. _ . City 7crrcn Ripon Owners Name __An e_lo Rebagliati_- phone 524-4967 Address '1. : 0M Gulfstream Dr. city Modesto! Ca. ,01010 Contractor's Name Herinings Bros. License l'2-9-92F 13 (3usiness Phone Contractor's Address 3525 Pelandale AVE. 11_ Mod 1,S}�PrdPnry Phone 545-027 IS Ceftlficate of Workman's Compensation Insurance on Fns With S.JLHD? Yes X No TYPE OF WORK(CHECK;_ NF_W WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION❑ WELL ACANDONMENT ❑ OTHER ❑ FUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Sep!ic Tank 801 Sewer Lines Fit Privy Sewage DisposeIField got Cesspool.'Seepage Pi: Other_ _. FrOrlerty Line Private Uornemia Well Public Domestic Well. _.. INTENDED USE TYPE OF WELL ❑ INDUSTRIA( ❑ CABLE TOOL Dia, 01 Well Excavat on 11” DOMESTIC/PRIVATE n DRILLEC Dia of Well Casing 61, PV'C _ ❑ DOMESTICiPUBLIC ❑ DRIVEN Gauge of Casing -- 160 W�LL ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 501 _ ❑ CATHODIC PROTECTION ROIARY Type of Grout BE TONITE ❑ DISPOSAL ❑ OTHER Other Information_SLAB--BY MA`"TER ❑ GEOPHYSICAL Su•face Sea Installed By: JR11 LER PUMP INSTALLATION; I Contrac!or r 1 2 Type of Pump H.P PUMP REPLACEMENT: J f d State wo•k DoneColl PUMP REPAIR: ❑ GtatF Wo•k Done DESTRUCTION OF WELL - Odell Diameter_ Aoproxrinata Depth — 0T/+l�r<� �1�. /D.es.-tibi Material and Procedure 1 hereby certify that I have prepared th s application anc alai ttip work w I he done in accordance wit((Sen Joaquin County ordinances state laws,and rules aind regulations of the Sari Joaqu n Lica Health District. Home owner or licensed agent's signature certifles the tollowing:'I corlity that i-i Elle performance of the work for which this permit is issued, I shall not employ any person in 5L.Ch manner as to ocrcome sub.oc!to workman's c:ornper;Felon Jaws of Californ,a." Contractor's hiring or sub-contracting signature certifies the following;`l certify:hat in the pe forn-anc.,or the~York ror wh ch this Perm It is issued. I shall employ persons subject to worKM,.'l's cora-pensatinn aws of Califo,nla. call for a Grout pection prior.to 10FOUNfIg and al inspection • ®n '/ Signed X z_a_- 1 r Date; I •a.v Piot Plar nr a r�p Sid=) FOR DEPARTMENT USE ONLY PHASE I ApplicaJun Accepted .-s"- AdCitional Comments: P d 11 Grout Inspection "ja--.jary spection 7 Incr.oct on By ! � Date��/�/_ Inspection By 44)4na+^ Fee Is Due: ❑ ANNUALI Y ❑PEA UNIT ❑ PEA SITE ❑EACH ❑ Jan-111V A`rIaLC1VC � .nd. S AsceH+.ed By July!I BILLING H061 TTANGE 5 KE MIT BASF EXPLANATION DATE UAYE HEV.IIlEJ al^CUs:'LsuE CHECKED AMOUNT FEE LESS — PRORATION PLUS PENALTY OTPiER I OTr rER Received by Dat,, lerr pi '.o :•ri i Nc lsaiancr Onir Mi let! Demvrnxt APPLICANT—RETUINI ALL COPIES TO ENVIRONMENTAL NEALTIi PERMn.SER VICES 101 E.HAZELTON AVE,,P.0 Box 2130111 STOCXTON,CA 95