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.1 Applications Will Be Processed When Submitted Properly Complet SereTo Sign The Applictbib FOR OFFICE USE: APYLICATION ,fir �(1�� (For Non-Transferable, Revocable, Suspendable)APR ( J ENVIRONMENTAL HEALTH PER PU P&WELL ��N ,�OAQUIN LOGA4 0� (COMPLETE IN TRIPLICATE) WATER QUALITYHEgLTH DISTRICT O I Application is hereby madetotheSan Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is N made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. W Exact Site Address Pilot Well No . 6 City/Town Lathrop -D Owner's Name _Occidental Chemical Co. Phone 858-2511 Address 16777 So. Howland Road City Lathrop , Ca. 95330 Contractor's Name Water Development Corp. License# 283326 Business Phone 916 662-2829 Contractor's Address 220 N. East ST ,Woodland, 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 CR DEEPEN ❑ RECONDITION❑ DESTRUCTION[2 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 inch ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing — ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -- J ❑ CATHODIC PROTECTION ROTARY Type of Grout ` ❑ DISPOSAL ❑ OTHER Other Information �J P 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 i n Ph Approximate Depth 150--200 f eet Describe Material and Procedure COMP, t P1 out seal from total de th to surf a.eP, placed through drill pine or tremie loe. 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. J Home owner or licensed agent's signature certifies the following:"I 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 compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I call to Grout Ins ipgpnor to grouting and a f' coon. Signed — - Title: Y SaS�_�Q� Date-Mk,(:Q (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date Additional Comments: Phase II Grout Inspection Pt s Final Inspection 3 �� Inspection By D Inspection By ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received ByVianuary 31 ❑ Jul 1 d[Rddt;eived y July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DAMOUNT DUE CHECKED ATE DATE REMITTED AMOUNT FEE " LESS PRORATION PLUS PENALTY OTHER OTHER X33 2 y% ,iso Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201