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Applications Will Be Processed When Submitted Properly Completed. BeSureTo Stg_2,TneApplication <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WI^I,I, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Appl ication 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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Occidental Tank Farm Mckinle Rd City/Town Lathrop <br /> Owner's Name Occidental Chemical CO Phone 858-2511 <br /> Address — 16777 S . Howland Rd City Lathrop <br /> Contractor's Name Clark Well & Equip License#371560 Business Phone 462-5597 SZ <br /> Contractor's Address 2024 E. Charter Way.-- Emergency Phone NA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT E] in Occidental Tank Farm <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 2 51 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 911 <br /> AZ INDUSTRIAL monitor ❑ CABLE TOOL Dia. of Well Excavation <br /> W DOMESTIC/PRIVATEE;tandards ❑ DRILLED Dia. of Well Casing <br /> 13DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing Class 1 60 PSC <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 34f <br /> ❑ CATHODIC PROTECTION 12 ROTARY Type of Grout sack mix <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done \� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe Material and Procedure <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 /> Home owner 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 emplo any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hirin ors -contr i nature c ifies the following:"I certify that in the performance of the work forwhich this <br /> permi i sued sh I m to er n subjec orkman's compensation laws of California." <br /> I f it p, ' n pri o u g an a final inspection. <br /> Signed X Title: V -Clark Well & Equi-P Date: Au ,1 80 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I CJ <br /> �S elDApplication Accepted By Date <br /> Additional Comments: <br /> Phase II Grout inspection Ph III Final Inspection ,y O <br /> Inspection �y KDate Inspection By ate a <br /> Fee Is Due: ❑ ANNUALLY ❑ PEA UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �FESSRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> > ha <br /> Received by Date Receipt No. Permit No. i4suancle Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />