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Applications Will Be Processed When Submitted Properly Completfte1&4TooIg"n Tne PlAlii it. f,"OR OFFICE USE: --APPLICATION i� (For Non-Transferable, Revocable, SuspendablAPP 7 1980 PUMP&WELL ENVIRONMENTAL HEALTH PEWK JOAQUIN LOrAL °Q (COMPLETE IN TRIPLICATE) WATER QUALITY J„H'l`w�ALTH DISTRICT � Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is i made in m liance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. I`r Exact Si e A ess Well No. 5 City/Town Lathrop Owner's Name Occidental Chemical Co . Phone 858-2511 Address 16777 So. Howland-Road City Lathrop , Ca. 95330 Contractor's Name Water Development Core 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 WORT( (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONRI 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 in_ah ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -- ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -- ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -- v ❑ CATHODIC PROTECTION ® ROTARY Type of Grout - ❑ DISPOSAL ❑ OTHER Other Information X 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 Depth150--200 feet Describe Material and Procedure cement rout seal from total depth to Urface�, placed through drill pipe or tremie Dipe. _- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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 It is I ed, I shall employ persons subject to workman's compensation laws of California." I w I call Gr t I s ction prior to grouting and a lindTnIon. Signed Title: ` -'s, A�� Date:Ni 11AA � n (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I (,� Application Accepted By Date 7 ?'J Additional Comments: P se II Grout Inspection III Final Inspection Inspection By ate Inspection By to T4 1 "A�� Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received R January 31 L� July 1+&R ived By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DAMOUNT DUE CHECKED ATE DATE REMITTED AMOUNT FEE �3. Ch � - LESS PRORATION PLUS PENALTY OTHER OTHER 05-33 Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRGUNWNTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201