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i % Applications Will Be Processe- en Submitted Prcpi rly Completed. fie Sure To Sign %ppttcahon. FOR OFFICE USE: APPLICATION (For Non•TransferablP, Revocable,Suspendable) i PUMP:WELL L ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application Is hereby Je to the San Joaquin Local Health District for a permit to consUuct and/or Install the work heroin descr,bed This application us ma•-te n compliance with San Joaquin County Ordinance No 1862 and the rules Awl regu,atlons of the San Joaquin Local Health D,strict Exact Site Addres%500' -,nest of Louise & Howland Site # 14 city Town Lathrop Own. Name Occidental Chemical Co. Phone 858-2511 .- Add uss 16777 S. Howland City Lathrop , Contractor's Name Clark Well & Equipment Licenser m 371560 Business Phone 462-5597 Contrnclor'c Address 2024 E. Charter Way Emergency Phor NA is Certificate of Workman's Compensation Insurance on File With SJLHO't YF-% No V� TYPE OF WORK (CHECK) NEW WELL 91 CCEPEN ❑ RE_CONDITiON❑ DESTRUCTION❑ WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP IN`. TALLATION❑ PUMP REPAIR C3 REPLACEMENT❑ in open f�eld DISTANCE TO NEAREST, Septic Tank ewer Lines Pit Privy i Sewage Disposal Field cesspool Seepage Pit Other Property Line Private Domestic Well Publ-C Dome,tic Well INTENDED USE TYPE OF WELL 12N ® INDUSTRIAL monitor 13 CABLE TOOL ),a of Well Excavation 5d DOMESTIC/PRIVATE standards❑ DRILLED D a of Well Casing 5 5/8~ ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 .Steel^ ❑ IRRIGATION 13GRAVEL PACK Depth of Grout Seal -761 ❑ CATHODIC PROTECTION IIS ROTARY Type of Grout SACk mix ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump ___-__ _ —_ H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter- _____.________ __. Approximate Depth Describe Material and Procedure 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County 4 ordinances,state laws,and rules and regulations of the San Joaquin Local Health District } Home owner or licensed agent's signature certlfles the following:-I certify that In the performance of the work for which this permit i is issued. I shall not employ any person in such manner as to become subject To workman's compensation laws of California" 1 Contractotag s tun Certifies the following:"I certify that m the performance of the work for which this rr AQ1 p rs n u a t to workman's Compensation laws of CRl lornia q ting and a final Inspection. Signed x ____ _ __ _ Title: VP-Clark Well & Equip Date• June_-23 E 1980_ raw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY 40 PHASE 1 l(1_ o W-7z-�O Appl cation Accepted By _ -.�4� -- _ Date Additional Comments ---.- _ Phis II Grout Ins tion/ —PUse!11 Final Ins Zion�f Q Inspection By C-�P atl9/Z 0 Inspection By - - Date (/l f f _ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ P SITE ❑ EACH ❑ January I a P&Celved By January 31 ❑July 16 Rwceivnl Ry July 31 REMIT BILLING REMITTANCE ti BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE -2:'. Lf 3 LESS PRORATION PLUS PENALTY OTHER OTHER Rwc wwwd t» had• nwr wqa No Permit No sxuance Da'a Madsd DelwarwJ APPLICANT—FIVIURN ALL COPIES TO, ENVIRONMENTAL HEALTH P[AMITISERVICES 100i E.HA2[LTON AVE.,►.O.aes[SSS STOCKTON•CA - ;