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Applications Will Be Processed When SL.,,, :.y Compl �.BBIAL��$i�1�1e�pii� FOR OFFICE USE: r"`.Irr.ICATION (For Non-Transferable, Revocable,Su abl'eAPR I 1980 OQ. r=1� Q ENVIRONMENTAL HEALTH PERMIT PUMA&WELL N JOAQUIN LOCAL QUALITY SA (COMPLETE IN TRIPLICATE) WATER 4 nI TRICT N Application is hereby made to the San Joaquin Local Health District for a permit to construct and/o �#t� cfrk 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 PilOt Well NO . 7. City/Town Lathrop Owners Name QC.ri rloni;a.l Chemical Co. Phone 858-2511 Address 16777 Sn-TTowl a nd Road City Lathrop , Ca. 95330 Contractor's NameWa tPr T)Pvpl opment Corp license# 283326 Business Phone (916) 662-2829 Contractor'sAddress29C) N_ EAst S . Woc)d1n.nd Ca.. Emergency Phone 916) 662-2829 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No TYPE OF WORK (CHECK): NEW WELL 9 DEEPEN ❑ RECONDITION❑ DESTRUCTIONE WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 5 i_n(-.b ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - �t ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -- ❑ CATHODIC PROTECTION ROTARY Type of Grout - ❑ 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 5 _inch Approximate Depth 150-200 feet Describe Material and Procedure cement grout Seal from total depth to sijrface, placed through drill -pipe or tremie pipe . " 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 regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit �1 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-contracting signature certifies the following:"I certify that in the performance of the work forwhich this s issued, I shall employ persons subject to workman's compensation laws of California." I w'I cal a Gr t In tion prior to grouting and a Fina sp n. Signed(];:: Title: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By C Date Additional Comments: Phase 11 Grout Inspection Phase III Final Inspection inspection By��Date 3 g Inspection By n 4 ate 3 s� a�iiJ Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE EACH ❑ January 1 R Received By January 31 July &Received By ly 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT OUfi CHECKED PATE OATS REMITTED FEE � y3 C� �!3 LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered APPOGANT—RETURN ALL COPIES TO: ENVIRCNMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 .STOCKTON,CA 95201