80-237 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly,COmplet�P$e&r1ky0g)LTJAgic FOR OFFICE USE: +- APPLI�CATION (For Non-Transferable Revodable, SuspendableAPR �J f[ j 1980 P P&WELD ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JOrlkAQUIN LOCALCQ Application is hereby made to the San Joaquin Local Health District for a permit toc� /'of�stf nstructand �tllta®rIj"'Ojecribed.Thisapplicationis G 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 Pi l nt WP11 No. 4 City/Town LathrOD Owner's Name Occidental Chemical_ Co. Phone :,858-2511 v Address 16777 So Howl and Read City Lathrop' Ca. 95330 Contractor's Name Water Deve1_0pnt Cory). License# 283326 Business Phone (91 i) 662-2829 Contractor's Addres220 N. East St _Woodla.nd, CS_._ Emergency Phone ( 2-2829 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONW 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 Excavationes i n rh ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -- ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -- ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal — ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout. — ❑ DISPOSAL ❑ OTHER Other information W GEOPHYSICAL Surface Seal Installed By: J PUMP INSTALLATION: Contractor _J Type of Pump H.P, 'J PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well DiameterrJ i nPh Approximate Depth150-200 feet Describe Material and Procedure cement front Seal from t0 de th to surface. Placed through drill pipe or tremi e1s ip_e_.. 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. Home owner or licensed agent's signature certilies the following:"I certify that in the performance of thework forwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." r Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." call for a out In ecti rior to grouting and a fina ection. Signed XTitl ti?S IL 4lk � Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY b PHASE I wo O Application Accepted By � - Date Additional Comments: h II Grout Inspectio f P Ill Final Inspection,/ / Inspection By Inspection By at� 33 f AAA;/ 4 Fee Is Due: El ANNUALLY 13 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &%Receive By July 31 BILLING REMITTANCE $ REMIT BASF EXPLANATION GATE HATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE - LESS PRORATION PLUS PENALTY OTHER OTHER C]j 33 s ... y/J--/S-v Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201