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Applications Will Be Processed When Submitted Properly Completesq�10bn meAppjiva.r4R•]1 71 FOR OFFICE USE: APPLICATION �J L.:� (For Non:Transferable, Revocable, Suspe ) ApIR i 1980OMP&WELL ENVIRONMENTAL HEALTH PERMIT UI[q LOCAL oq (COMPLETE IN TRIPLICATE) WATER QUALITY SAN �OAQ js-[?,CT CT 0 ,,,,t� h rein described.This application is I Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instf{ lfr� 9-) made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. S Exact Site Address City/Town ILa.t Owner's Name Occidental Chemical Co . Phone 858-2511 Address 16777 So. Ho,1dAnd__R_0_a_ City Lathrop, Ca. 95330 Contractor's Name Water Deve10 Ment COr . License# 283326 Business Phone 916 662-2829 Contractor's Address 220 N_.- E a-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 [3 RECONDITION❑ DESTRUCTION IR WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 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-]30-b ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION k] ROTARY Type of Grout - ❑ DISPOSAL ❑ OTHER Other Information y ® GEOPHYSICAL Surface Seal Installed By: V PUMP INSTALLATION: Contractor .� Type of Pump H.P. ` PUMP REPLACEMENT: IJ State Work Done V PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter 5 inch Approximate Depth 150-200 feet Describe Material and Procedure cement grout Seal from total depth ` to surface laced through drill pipe or tremie 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. 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 forwhich this i permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call 1 a Grout Ins tion prior to grouting and a tin4L+� ion. Signed - Title`: Date: Cc (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY r // // PHASE I _T 1 /g O Application Accepted By bate [�7[ Additional Comments: Ph 8 h Grout InspectionPf s Final Inspection D Inspection By ate 3® Inspection By 1 to Fee Is Due: El ANNUALLY El PER UNIT El PER SITE 13 EACH El January 1 &Received By nuary 31 ❑ Jul & ec�,,,.d5, 31 REMIT RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE � Y 3 f/1 LESS PRORATION PLUS PENALTY OTHER OTHER C53 Y6 WflFn Received by Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIESITO: ENVIRONMENTAL HEALTH PERMrf95ERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , .,,. ....