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Applications Will Be Processed When Submitted Properly Compleled. u1WJ6TJ 64plWtitui R FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspen 41 198 MP&WALL ENVIRONMENTAL HEALTH PERMIT y` t WATER QUALITY USN '-C"� L OCA (COMPLETE IN TRIPLICATE) SAN ,JCJAQ ��1��RI ,T C Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instaPFftTA+ escrl ed.This application is t made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. 9- Exact Site Address pilot Well No. 12 City/Town Lathrop Owner's Name Occidental Cherna.cal Co. Phone 858-2511 Address 16777 So. Howland Road City Lathrop, Ca. 95330 Contractor's Name _Water Development Corp. License# 283326 Business Phone (916) 662-2829 Contractor's Address 220 N. East S _,Wo_o_rland�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 IR DEEPEN ❑ RECONDITION❑ DESTRUCTIONIR 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 '1 nnh ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -- ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -- ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal — ❑ CATHODIC PROTECTION ROTARY Type of Grout -- ❑ DISPOSAL ❑ OTHER Other Information FD 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 in h Approximate Depth Describe Material and Procedure cement out Seal from total depth to surface , lola.cpd throligb drill 1):Lpe or i 1 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. Homeowner 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 i sued, I shall employ persons subject to workman's compensation laws of California." will c II for a rout I ect' rior to grouting and a fin Ins ion. Signed X Till Date �2 '. (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I 1 Application Accepted By --_ Date Additional Comments: Phase II Grout Inspection p 4By 1 f=inal inspection Inspection By ate a5 a D Inspection By ate 3 D Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Recy 31W❑ July 1"&ReceAveb By Ju 31 REMIT I BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED (�7 f DATE DATE REMITTED AMOUNT FEE `7 J VZ "lr3 LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. issuarice Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201