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Applications Will Be Processed When Submitted Properly Completed. Be reJ1 &'fgr41ThTA_111ic�n� j{ FOR OFFICE USE: APPLICATION rte 1 V `f` y } `y{ (For Non-Transferable, Revocable, Suspend G�19WP&WELL ENVIRONMENTAL HEALTH PER APR (COMPLETE IN TRIPLICATE) WATER QUALITY AoUlIq LOCAL- OG Application is hereby madetothe San Joaquin Local Health Districtfora permittoconstruct and/or inst�blRxh A .Arq6IVFr�Q'T.This application is D made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of theli"� quln Local Health District. I Exact Site Address P_l.JDt__Xe11 No City/Town Jla_t_P -� Owner's Name Occidental Chemical Co . Phone 858-2511 f Address City Lath—rop, Ca. 95330 Contractor's Name Water Development _CQr J. License# 283326 Business Phone (916) 662-2829 Contractor's Address 220 N. East 8t I,Woodland ,Ca Emergency Phone ---"96 662--2829 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL U DEEPEN ❑ RECONDITION❑ DESTRUCTION U 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 J_rt c-h ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -- ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal — ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout -- ❑ DISPOSAL ❑ OTHER Other Information PrGEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor 11 Type of Pump H.P. ,S PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done J DESTRUCTION OF WELL: Well Diameter 5 inoh Approximate Depth 1 50-9,00 f tact J Describe Material and Procedure cement grout s .al from total depth _ 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." wilt call Grout Insp prior to grouting and a fin ns e on. [ - r Signed X �� Title: S, 1",-,, \ Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date Additional Comments: Phase II Grout Inspection` T t Ili Final Inspection Inspection 8 _ Date b'- 2S6 Inspection By ate f d Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 E,Received By J nuar 31 �i ' y ❑ July 1 &Receroed By uEy 3t BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT OUF CHECKED FEE C{3 C�, 3 AMOUNT LESS PRORATION PLUS PENALTY OTHER OTHER c. Received by Date ©D Receipt No. Permit No. Issuan a Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201