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Applications Will Be Processed When Subn:,tted Properly Complit&e Sure To Sign The Appl(eeltl5n. FOR OFFICE USE: AP-011CATION APR 7 1980 (For Non-ffansferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PEfgiW JOAQUIN LOCAIUMP&WELL O HEALTH DISTRICT (COMPLETE IN TRIPLICATE) WATER QUALITY i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is . made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. ' Exact Site Address P i l City/Town Owner's Name Occidental Chemical Co . Phone 858-251.1 Address 16777 So. Howland Road City Lathrop Ca. 95330 Contractor's Name Vater Development Corp. License# 283326 Business Phone (916) 662--2829 _ Contractor's Address 220 N. East St ,Woodland, 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 12 DEEPEN ❑ RECONDITION❑ DESTRUCTION 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 inch. ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -- ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -- ❑ CATHODIC PROTECTION JO ROTARY Type of Grout -- ❑ DISPOSAL ❑ OTHER Other Information R GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H P ` PUMP REPLACEMENT: ❑ State Work Done V PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter S i nrh Approximate Depth. 154-200 feet Describe Material and Procedure cement gro t seal from total depth to�BlIrfa.pe p1 ac,Pd through drill ppP or tremie pip-e-.- 41 ipe4' 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 C 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 ued, I shall employ persons subject to workman's compensation laws of California." will all for a rout I eci' prior to grouting and a fi a�inlion. Signed X Ti _ C c�5' �Arti Date. I ' `b`YC �l (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I 7 Application Accepted By - Date Additional Comments: , pase Grout Inspection Q Ph a inal Inspection Inspection By v ate 9- V Inspection By to T i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By J uary 31 ❑ July 1 S Rec ive By Jul 31 REMIT 71BAE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE y �yL 4 / LESS PRORATION PLUS PENALTY OTHER OTHER -5-3 3 9 �o Received by Date Receipt No ermit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201