80-224 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora 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 P . ot_We 11 No. 2 City/Town __L.a.t_h P Owner's Name Occidental Chemical Co_. Phone 858-2511 Q Address ____ 16777 So_ Howland R.oa.d. City Lathrop, Ca __95330 Contractor's Name Water Development Corp._ License# 283326 Business Phone_(916)_-.6-6.2-2.829 0 t Contractor's Address 220 N. East St . ,Woodland,f aEmergency Phone {,91.6_} 662'Z829 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X. No TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION CR WELL CHLORINATION © WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El 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 ch m ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -- ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -- ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal __ V ❑ CATHODIC PROTECTION g ROTARY Type of Grout -- ❑ DISPOSAL ❑ OTHER Other Information q 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 1.50-200 ft . Describe Material and Procedure cement yrout Seal from total depth to surface laced 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. 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." p tion prior to grouting and a final ' n. ` Signed X =Csr.—, Title Date: Wa_t,-t, 7-8 (Draw Plot Plan on Reverse Side) FO DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments. Phase 11 Gro t inspection Phase IN Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 3 LESS PRORATION PLUS PENALTY OTHER OTHER SI I F9 Received by ate 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 t --