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K , Applications Will Be Processed'. Submitted Properly Completed. B• Sure To Sign Tr 'lplieation FOR OFFICE USE: l APPLICATION j — (For Non-Transferable,Revocable,Suspendabis) ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Apphcatlon is hereby mach to the San Joaquin Local Health DoOnrt fora permit Incon%fruCt andior invall the worx hereindescribed This apphtation is made in Compliance with San Joaquin County nrljnlanLe No 1H67 aria Ir— rolen and regulations of the`;an JOa(J,un Local HPAltn D,,tt,wl Exact Site Address 500' west of Lt�uise & Howland Site-14 City,Town Lathrop Owners Name Occidental Chemical Co. Phone 859-2511 ' Address 16777 S. Howland City Lathrop Contractor's Name Clark Well & Equipment Lirem,r. x 37156o Business Phone 462-5597 V1 Contraclor's Address 2024 E. Charter Way Fmerger,cy PnrrR NA vii. IS Certificate of Workman's Compensation Insurance on File With SJLHD) vet No TYPE OF WORK (CHECK) NEW WELL® DEEPEN ❑ RECONDITION C3 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PLIMP REPAIR E3 REPLACEMENT El in open f, e1dL DISTANCE TO NEAREST, Septic Tank -_ ewer Ines Pit Privy Sewage Disposal Field Cesspool Se9pagR Pit Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL Y Q INDUSTRIAL monitor ❑ CABLE TOOL Dia of Well Excavation 12" EJ 8 DOMESTIC/PRIVATE Standard8❑ DRILLED Dia of Well Casing 6_. .. .__....._._.. 511 ...,,..,_,,._ ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauje of Casing 12. ►StiB.@,1....._ ❑ IRR13ATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC I ROTECTION 0 ROTARY Type of Grout 9 sack mix 0 ❑ DISPOSAL ❑ OTHER Other Information • ` ❑ GEOPHYSICAL Surface Seal Installed By =--T - -�Cr •s PUMP INSTALLATION: Contractor Type of PumpH.P. - PUMP REPLACEMENT: ❑ State Work Done_, PUMP REPAIR: ❑ State Work Done F DESTRUCTION OF WELL: Well Diameter- _.. __._-- __.__ Approximate Depth ��- Describe Material and Procedure.-- _,____,... I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin County ordinances,state laws,and rules and regulations of the San Joaquin LOCH Health District Home owner or licensed agent's signature certifies the following:"t certify that In the performance of the work.for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compen-whon laws of California— Contractor's hiring or sub-C s nature certifies the following:"I certify that.n the performance of the work for which this permit s issued, I shall a oy erg s eft to w kman's compensation jaws Of California" 1 w+ ora o ti o[t uUng a find Inspeetioe Signed x _ Title: VP-Clark Well & Equip D.a: _June_24,iQ@Q,Z (Draw Inn on Rove—Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted BY Date I Additional Comments: as Grout Insjpoic / / Ph se 111 Final InppaetloR Inspection By :- 1 rr�q�,,� n X11 n 6 S/8Q_�_. inspection By Date_� Jfi� Fee Is ,'ue: ❑ ANNUALLY ❑ PER UNIT '"�b❑�Y JItF ❑ FACH O JIInuAry I A Received By January 31 ❑ July I A`ec!.ved By July 71 ? I REMIT BASE EXPLANATION RREMITTANCE = AMOUNT OUE ;NECKED riATE ! DATE REMITTED i MOI 4•f FEE ——._ -- —� l-- -- 443 — -- LESS PROFIATION --_ PLUS PENALTY OTHER OTHER uPr.•.wl by _ - Dna ..._ - An, 10 N., IN—A No issuance Date Matted Dri.vered _._ APPLICANT—r1[TURN ALL COPIES TO tMVIRONMENTAL HEALTH PERMIT:SERVICES 1601[.NA2ELTON AVE.,PO.Dos 7009 STOCKTON.CA 95"1 r