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Applications Will Be Processed When Suhmitted Properly Completed.Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION Ab 71' (For Non•Transfe►ab!e,Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT :O!MPLETE IN TRIPLICATE) :LATER QUALITY -OPI cation is hereby made to the San JOaquin Local Health l for a permit to Construct and Or install the•work herein described This application is ade.n compliance with San Joaquin COUnty Ord;nan(V•No iH62 and Ih.- rules and regulations of the San Joaquin Local Health District iiaci Site Address 500' west of Louise & Howland City Town Lathrop wners Name Wells owned by Occidental Chemical Co Phone 858-2511 ddre::s 16777 S. Howland rely Lathrop CA- ontractori Name Clark Well & Equipment License IN 371560 Buv,r ess Phone 462-5597 O' ontractor's Address 2024 E. Charter Way Emergency Phone MA 11 Certificate of Workman's Compensation Insurance on Fife With SJLHD7 Yes No Y TYPE OF WORK (CHECK) NEW WELL DEEPEN ❑ RSCONDITION❑ DESTRUCTION❑ 'ELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR -EPLACEMENT❑ In open fief ,IS-I ANCE TO NEAREST Septic Tank Sewer ines P.!Onvy Sewage Disposal Field Cesspoul/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well -_ INTENDED USE TYPE OF WELL INDUSTRIALmonitor ❑ CABLE TOOL Dia of Well Excavation . 12" DOMESTIC'PRIVATE standardEO DRILLED Dia, of Well Casing 6 5/811 OOMESTIC'PUBLIC ❑ DRIVEN Gauye of Caning IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1.91! _ CATHODIC PROTECTION --ROTARY Type of Grout . -— —_ .---9-,-B.aCIcJn X 9 DISPOSAL ❑ OTHER Other Information I GEOPHYSICAL Surface Seal Installed By: IUMP INSTALLATION: Contractor Type of Pump --- --- -- H.P. -- ----F- 7 IUMP REPLACEMENT: ❑ State Work Dona IUMP REPAIR: ❑ State Work Dore _ ESTRUCTION 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 accoroanco 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 certlfy th,dt 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 compensation laws of California." 4 r Contractor's hlring or sub-contractin signature certifies the following:A certify that in the performance of the work for which this permit is issued. I s II y r ns suble to workman's compensation laws of California" I 1 for G 1 n g and a final Inspection. •Igned X _ .-_ - __ _ _ -_ _ -_ ___.__ Tule:VP-Clark-Well_& Equip. Date: _Nov.4,1980- _ (Dr Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE 1-00 Application Accepted By _- _-__.—_ Date -ff Additional Comments —- -- --- -- ---- - - - - - -- -- -- - ------- --- — (�Pha IIlGrrouttIIn,,spection I/J/ /p \ Phase III Final Inspection \\ \� Inspection By--C•.�'�r f)('^^'`Date _J/ //O Inspection By .1 --- _ Date V wmmsllb Fee is Due:❑ ANNUALLY Cl PER UNIT C3 PER SITE ❑ FACH 0 January 1•Re w-v ey Jai,uary 31 ❑ Juiy 1 A Recewe+l By JOY 31 ----- REMIT BILLING REMITTANCE I S BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT —dr'✓ --- - _ ev FEE ----- I - -- -- I -- -.0 q3 — --- -- LESS —� PRORATION PL US PENALTY OTHER OTHER Aer,vd Dv -. patw ---- Receipt No Perms No Issu a aaee Mailed Cel"Wed APPLICANT-RETURN ALL COMES TO ENVIRONMENTAL HEALTH PERMITAERy1CIS 1601 C.HAZELTON AYl.PO.aaa IOM STOCKTON.CA 96701