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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OF_,FtCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 <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 16777 S • Howland City/Town Lathrop <br /> Owner's Name Occidental Chemical Co. Phone 858-2511 - <br /> Address <br /> 8-2 11 -Address 1 777 S. Howland City Lathrop <br /> Contractor's Name Clark Well & Equip. License# 371 X60 Business Phone 462—5 597 0 <br /> Contractor's Address 2024 E. Charter Way Emergency Phone _ NA t <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 Cid OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ �} <br /> REPLACEMENT❑ located appox. + 30-501 from Monitor Site # 8a <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy . <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ® CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information A , <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �l <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. apprx. 1 4t' Approximate Depth 651 <br /> Describe Material and Procedure casing corroded sack m1 S n t) <br /> filled from bottom through pipe to - x m <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 /> Homeowner or licensed agent's sign a certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shall not employ any <br /> 'so in s manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contra ' signature erti ' s the f lowing:"I certify that in the performance of the work for which this <br /> permit is Lied, I sha emplo r ns su to rkma compensation laws of California." <br /> l will ro s n t outln al i spection. <br /> Signed X it VP—Clerk Well re F tti p Date: Nov. 1 9 .1R C) <br /> (Draw Plo Ian Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By M, '-' Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P se III Final Inspection <br /> Inspection By Date Inspection By i' Date V\, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE. $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �] AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION t <br /> r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by Date Receipt No. Permit No. Iss ance bale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2069 STOCKTON.CA 95201 <br />