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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION S (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinanceo. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Occidental Tamk Farm/Mckinley Rd City/Town Lathrop Owner's Name Occidental Chemical Co. Phone 858-2511 Address 16777 S . Howland City Lathrop Contractor's Name Clark Well & Equip License#371560 Business Phone 2-5597 Contractor's Address 2024 E. Charter Way Emergency Phone NA 0 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ J WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT 13 in Occidental Tank Farm 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 12 INDUSTRIAL monitor ❑ CABLE TOOL Dia. of Well Excavation 9n ®. DOMESTIC/PRIVATE Standard; ] DRILLED Dia. of Well Casing 11 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Class 160 PVC ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 219% ❑ CATHODIC PROTECTION EkROTARY Type of Grout 9 sack mix ❑ DISPOSAL ❑ OTHER Other Information ❑ 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 Approximate Depth m Describe Material and Procedure 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- ntraciing signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I Sh a plo p subjec o workman's compensation laws of California." I or a r t pr' r r g nd a final inspection. Signed X Title: VP-Clark Well & Equip Date: Aug 5 r 1980 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date S Additional Comments: Pae II Grout Inspection Q Phase III Final Inspectio Inspection By Dated .. �f � Inspection By Date -111 A N o Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED • ((�� ``J� �• � u AMOUNT FEE Et L4 tom'� I LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuancb Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201