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or Applications WIII Be Processed When Submitted Property Compleled. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION ,fl (For Non-Translerable,Revocable,Suspendable) 1 -- PUMP&WELL •• ENVIRONMENTAL HEALTH PERMIT Q (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is r made in complimice with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact SiteAddress 1_§3-75_ Milgeo R8 . eity/TDwn Upon Owners Name �Angelo Rebagliati Phone 524-1967 Address \. 2024 Gulfstream Dr. _ City Modesta, Ca. .00 -- •- Contractor's Name Hennings Bros. License M-?-9-9_.1 3 Business Phone 5F+5-11 46 Contractor's Address 3525 Pelanaale Ave. , Modest 18rgency Phone 545-0271 W Is Certificate of Workman's Compensation Insurance on File With SJLHD4 Yes X No -1 TYPE OF WORK (CHECK). NEW WELLIM DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ If) WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank _$0/ Sewer Lines Pit Privy _ Sewage Disposal Field 801 Cesspool/seepage Pit Other _ Property Line Private Domestic Well Public Domestic Well_.._.._ INTENDED USE TYPE OF WELL ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation... 11" M DOMESTIClPRIVATE ❑ DRILLED Dia of Well Casing .- 0, Pvc I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 60 WALL ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 50' ❑ CATHODIC PROTECTION M ROTARY Type of Grout BEhTTONITE ❑ DISPOSAL ❑ OTHER Other Information SLAB-'BY OWNER _ ❑ GEOPHYSICAL Surface Seal Installed By: DRILLU PUMP INSTALLATION: l Contractor r 1 Type of Pump Q7!r _ H.P- PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL Well Diameter_ Approximate Depth -IJ+ ( kj-it� Describe Material and Pr cedure I hereby certify that 1 have prepared this application and that tree work will be done in acc rdance with San Joaquin County ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this perm t is Issued. I shall employ persons subject to workman's compensation laws of California." I w I call for a Grout action prior.to groulln and I inspection, Signed X ___ --_ _ f Date. 9 (Taw Plot Plan on R rhe Side) FOR DEPARTMENT USE ONLY PHASE I Cy` Application Accepted r Date/_4-r' Additional Comments: 12,6 11 Grapt Inspection P 111 Final ape:uon Inspection By ! �"� Cate�%/ /7 l., Inspection By Date Fee IS Due: ❑ ANNUALI Y ❑PFA UNIT ❑ PEO 911E ❑EACH ❑ Jsmguy fl Necnred By Ja�uary 31 ❑July t b Received By July 31 BILLING HLMITTANCE S REMIT EXPLANATION AMOU DATE DATE REMITTED NT. DUE CHECKED _ AMOUNT FEE LESS PRORATION PLUS PENALTY — OTHER i OTHER 7n a (21-4 -7 -lo-7 Amaived by Dria raecapt No Nc. Isfuunce Date Ma-led DaNiwprw APPLICANT—RETUNN ALL COPIES To' ENVIRONMENTAL HEALTH PERNIIAERViCES INN E.HAZELTON AVE.,P.O.Boa 9001 STOCKTON.CA 95