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�i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Translerable, Revocable, Suspendable) PUMP&WEI,f. ENVIRONMENT& HEALTH PERMIT _ (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaqui n Local Health District fora permit to 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 Pilot Well No. 3 City/Town Lathrop Owner's Name Occidental Chemical Co. Phone 858-2511 9J Address 16777 So. Bowland 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 ..(9161.-662-2829 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTIONK] 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 -- ❑ CATHODIC PROTECTION 10 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 Depthl 50-200 feet, Describe Material and Procedure CAment grout Seal from total depth to slinFa.ct? , pl a-ced through drill 12JnQ or tremile 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. 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." Ll wil cal4for� Grout Ins ion prior to grouting and a final in e `Signed Title: tC` '�c�� Date: V, (Draw Plot Plan on Reverse Side) FOR EPARTMENT USE ONLY PHASEI Application Accepted By c Date Additional ( omments: I Z6 Phase II Grout Inspection �i Phase III Final Inspection Inspection By ate S ° C) Inspection B a e VV Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH 11 January 1 &Received By J ry 31 ' ❑ July 1 & i y Iuly 1 Flo REMIT BILLING REMITTANCE $ BASF EXPLANATION DAMOUNT DUE CHECKED ATE DATE REMITTED �J AMOUNT FEE .94 LESS PRORATION PLUS PENALTY OTHER OTHER 6 Received by Date Receipt No. Permit No, sua ce Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 5