80-938 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed.BeSureToSignTneappncarlon. FOR t+—,TCE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 400' North of Louise & Howland City/Town Lathrop owner's Name Occidental Chemical Co . Phone 858-2511 Address 16777 S . Howland City— Lathrop Contractor's Name Clark Well & Equip. License#371560 Business Phone 462-5597 Contractor's Address 2024 E. Charter Way - Emergency Phone NA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I T, WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ V 1" REPLACEMENT in open field p� DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 12" ID INDUSTRIAL monitor C3CABLE TOOL Dia. of Well Excavation FI DOMESTIC/PRIVATE Standards DRILLED Dia. of Well Casing 6 81� ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 Steel ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal approx. 68" ❑ CATHODIC PROTECTION 12 ROTARY Type of Grout Q 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 I hereby certify that I have prepared this application and that the work will be done in accordance with SanMCounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certity 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 compensation laws of California." Contractor's hiring or sub- ntracting signature certifies the following:"I certify that in the performance of the work for which this *permitssued, I sh empo r ns subj t to workman's compensation laws of California." r p on g g and a final inspection. SignedX Title: VP-Clark Well & ui . Date: OV. 6 1 80 I (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I �O Application Accepted By Date UU Additional Comments: �ha I Grout Inspection rr �'} [Pas�[III Final Inspection 3 Inspection By Date f! v Inspection By �y — ` Date �� \ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS �+ PRORATION PLUS PENALTY OTHER OTHER J16 Received by Date Receipt No. Permit No. IsquancelDate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 209 STOCKTON,CA 95201