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Applications Will Be Processed When Submitted Properly Comple � e�j,4a'gir� AA1lic FOR OFFICE USE: APPLICATION II�� (For Non-Transferable, Revocable, Sus ble}AP f 7 1980 PUMP&WELL ENVIRONMENTAL HEALTH PERMIT WATER QUALITY SAN JOAC �IN LO COLL (COMPLETE IN TRIPLICATE) STRICT � ApplicationisherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/oril#�1WA�� r ereindescribed.Thisapplicationis Q made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. t Exact Site Address 'Pilot WP1 1 No. 1.3 City/Town Lathrop Owner's Name Occidental Chemical Co . Phone 858-2511 Address 16777 So. Howland Road City Lathrop , Ca. 95339_ Contractor's Name Water Development Corp. _ License# 253326 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 a DEEPEN ❑ RECONDITION❑ DESTRUCTION IR 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 11 DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION Q ROTARY Type of Grout — DISPOSAL ❑ OTHER Other Information GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor d Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done - PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter 5 1nab Approximate Depth -1.5D-2DD e et Describe Material and Procedure cem�_v__,ent_ grrnIt. gPa1 f-rOm total dP.pth t-O S13.rf P..rQ rp l�l,r'Ad through drill pipe or tremae 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." wi call for Grou peVn prior to grouting and a fin ns c Signed X � ' Date: � (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date �� Additional Comments: P se it Grout Inspection P s Final Inspection 7 �oInspection By Date Inspection By T Fee Is Due: 13 ANNUALLY ❑ PER UNIT 11 PER SITE El EACH 11 January 1 &Received 8y J vary 3i ❑ July 1 �Fleceive By Ju 31` BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED ' AMOUNT FEE 1 C J q3 LESS PRORATION PLUS PENALTY OTHER OTHER ds3W q/ff/,fC Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.IiAZELTON AVE.,P.D.Bor 2009 STOCKTDN,CA 95201 l