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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR &-- ICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora 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 1677 S, Howlard City/Town _ I'athrop owner's Name Occidental Chemical Co. Phone 858-25 -1 � Address 16777 S . Howland City_ Lathrop r Contractor's Name Clark Well & Equipment License#_71560 Business Phone62. �� v Contractor's Address 2021' E. Charter Way _ Emergency Phone _ NA (� - s Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ® OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ in open Field DISTANCE TO NEAREST: Septic Tank SewePLines 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 app. tt ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor _ Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done 1 PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter 811 Approximate Depth Describe Material and Procedure remove _pjjmp--Btuck 1n W21 l_&—place � 9-sack mix(sand & cement) from bottom9 top 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 a such manner as to become subject to workman's compensation laws of California." Contractor's hiring sub-contractin n certille he following:"I certify that in the performance of the work for which this permi is i sued I s all oy ns bj t to w an's compensation laws of California." 1 yy# to spe i p lot t inal inspection. �-- Signed X isle: VP-Clark Well Date: July 223,1.981 - (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By Date Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 BILLING REMITTANCE S REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 9 D Com. } boo LESS PRORATION _ PLUS PENALTY OTHER OTHER 71a317S Received by Date Receipt No. Permit No. I uance Da Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 .