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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FQfi OFFICE USE: APPLICATION <br /> i <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> j ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. t <br /> Exact Site Address Pilot We 1 1 No, 15 City/Town La thiroP <br /> Owner's NameOccidental Chemica1 Company . Phone 858-2511 v <br /> Address 16777 So. Howland Road City_ Lathrop, CA. 953.0 <br /> Contractor's Name Water Development Corp. License#283326 Business Phone (916) 662-2829 <br /> Contractor's Address _3 220 N. East St. Woodland CA-Emergency Phone (916) 662-282 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL q DEEPEN ❑ RECONDITION❑ DESTRUCTION Eli <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 5 inch <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing '- <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -- <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> 4� <br /> ❑ DISPOSAL ❑ OTHER Other Information V <br /> R GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor v <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameterinch Approximate Depth 150-2 <br /> 00 <br /> Describe Material and Procedure r_PmPnt_grout seal from totaA—d p <br /> irfa.^a Placed thr—ci j dr'i 1 1_n i P car tr .ml pi-pe, <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqu <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performanceof the work for which is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Co . <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I hall employ persons subject to workman's compensation laws of California." <br /> 1 II f a rout Inspection prior to grouting and a final i s ecti <br /> � in Harris , <br /> Signed X TitleManager� Fnvi rnnment_Heal t1- Date- May 27, 19817 <br /> (Draw Plot Plan on Reverse Side) & Safety <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date C <br /> Additional Comments: <br /> Phase II Grout Inspection Pha a III Final In 1i I 3 g <br /> Inspection By Date Inspection By at <br /> 611 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Rectived By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Tlermit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> w <br />