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FOR OFFICE USE: APPLICATION ' (for Non-Transferable, Pevocable,Suspe-ndabk•) (L",5P Zt �'iELI IVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY t,p,j�cr!.,)n hereby rnar?n to the ian Joaquin L oval Health Oistnct fc1f a pvrrTW to con•itruct and%or Install thework harem descntu d ThrS Applrta9c+n 13 made In cornplianCe wor,San.'oagcnn CrJunty Ordwance No 1862 an:? g requlaheris of thr•San Joa.j,nn LOCAI Health District Exact Site Address 500' west of Louise & Howa.and ��" 0tyrTown Lathrop Owner's Name Wells owned by Occidental Chemical Phone 858-2511 Address 16777 S. i.owland City Lathrop Contractor's Name Clark Well & Equipment License Biro,^Ir$s Pnone 462-559? y� Contractor's Address 2024__E. Charter Way _ . Emergency Phony NA - --r-� Is Certificate of Workman's„ampensation Insurance on File With SJLHD'/ Yes No TYPE OF WORK (CHECK) NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT In open field DISTANCE TO NEAREST Septic T ank ewer Lines P t Privy - Sewage Disposal Field Cesspool/Seepage Pit _ Other ---- t Property Line __— ._-- Private Domestic Well Public Domestic Well ----- • INTENDED USE TYPE OF WELL 12n 91 INDUSTRIAL monitor ❑ CABLE TOOL Dia of WAIT Excavation 6 5/811 --— ---- ---- FI ® DOMESTIC,PRIVATE standardEO DRILLED Dia of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _12.Stee,1,_ e ❑ 'RRIGATION 13 GRAVEL PACK Depth of Grout Sent 21 ❑ CATHODIC FROTECTION IN ROTARY Type of Grout 9 (sack mix ❑ DISPOSAL 13 OTHER Other Information — .e ❑ GEOPHYSICAL Surface Seal Installed By. xr PUMP INSTALLATION: Contactor !, Typo of Pump _._ ,. _.. H P. PUN10 REPLACEMENT: ❑ Slate Work Done PUM?REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter _ —_-__, - Approximate Depth Describe Material and Procedure I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,state laws,and rules and requlations of the San Joaquin Local Health District s Nome owner or licensed agent's signature certifies the following: 'I certify that in the performance of the work for which this parnit �s issued. I shall not employ any person in such manner as to becc ne subject to workman's compensation laws of California" Contractor's hiring or sub-eonlrecting signature certifies the following:"1 certify that in the performance of the work for which this `,. permit is ISSUPA�I shall emplo persons subject to workman's compensation laws of Californiayri ." 1 1 call or I Prior grouting and a final inspection. signed X _'. `J Title: VP-Clark Well & Equip. Date: _June_.19,.198 _ 0 . • N(Draw Plot Plan on Reverse Siete) 3 7 FOR DEPAR ENT USE ONLY E PHASEI Application Accepted By-- .-__. /L��J s! J ---. - Date jllLli.r ti •; Additional Comments --`--- --------'-- _ ------ .Pse 11 )Grout inspection a III Final Inspection By h Inspectlorr By / Inspection B 6 .��/ � � Date �' M-�----_ �_•_ die 7 f��._ , 777 Fre Is Due:O ANNUALLY (3 PER uNr' ❑ I'Fn`a,F. ❑ EACH ❑ Jenusrr 1 d Glecerved By JenWlrY 31 Cl `.w 1 3 Receweo By July Jt j F-__ r__ _... -- -- --- . .. REMIT...._ BASE I EXPLANATION BILLING REMITTANCE REMITTED -_ -AMOVNT DUE _ -_ CHECKEDAMOUNT DATE OATS REMITTED AMOUNT ,;,7 I -----——rt-- --- — FEE t LESS L,-: PLUS -a PENALTY ....._.- = I i; OTHER OTHER Rece•ved by Date Receipt N) Permit No Is. •ace t. k4rNd DNnrrW _. APLICANT—RETUaN ALL COPIES TO: ENVIIIONMENTAL HEALTH PERMIT/etaVICEe teal t.HAZELTON AVX.,P.O.a..tsse tTOCxTON.CA M„/ P 2 , AY '3a