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Applications Will Be Processed When Submitted Properly Complete � <br /> FOR OFFICE USE: APPLICATION - nheuApcat <br /> j (For Non-Transferable, Revocable, Susp e) '�g80 <br /> ENVIRONMENTAL HEALTH PERMIT APR PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN nj0 AQ JIN LDISTRATL <br /> CC is hereby made to the San Joaquin Local Health District fora permit to construct and/or insl�IFtIOJ 'k <br /> This app <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San JoaquinlLo alcHealltth District.cation is Q <br /> Exact Site Address Pilot Well No , 10 <br /> City/Town Lathrop � <br /> Owner's Name Occidental Chemical Co . t <br /> Address _ 6 X77 So. _ Howl n Road <br /> Phone 858-2511 W <br /> Contractor's Name Water DevelO ment Cor City��; <br /> License# 283326 Business Phon -Lal_6) 562_2829 <br /> Contractor's Address 220 N. E�.St St Woodland Ca..Emergency Phone 916 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes g 662`2$29 <br /> TYPE OF WORK (CHECK): NEW WELL CR DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR I] <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> 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 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED _ <br /> Dia. of Well Casing ` <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout _ } <br /> ❑ DISPOSAL ❑ OTHER Other Information V <br /> ® GEOPHYSICAL Surface Seal Installed By: J <br /> PUMP INSTALLATION: Contractor J <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 5 inch Approximate Depth 150-200 feet <br /> Describe Material and Procedure Cement grout Seal from total de th <br /> to surface laced through drill -parie or tremie pipe. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <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 performance of the work for which this permit <br /> ' is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this ` <br /> Pe Is I shall employ persons subject to workman's compensation laws of California." <br /> I will call for t In qtiaM prior to grouting and a firmo4nsputction. <br /> t11 <br /> SignedTitlCU\ e: ,I Date: _ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> —Phau II Grout Inspection a III Final Inspection Inspection By Date Inspection B r+�Ah-spatV2/1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PEH SITE ❑ EACH ° <br /> ❑ January 1 &Received y January 37 ❑ July 1 &Receive By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �� <br /> FEE Ct AMOUNT <br /> G� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Sa <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE-.,P.O.Box_2.009._ .STOCKTON-cAns2nf <br />