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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. v <br /> -FOR ONFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Site near # 8a 16 S . Howland City/Town Lathrop <br /> Owner's Name 1 ChemiCal Co. Phone 858-2511 <br /> Address City La floD <br /> Contractor's Name Ozark Well & Equip License# 371560 Business Phone_ 462- 597 y` <br /> Contractor's Address 0 h r 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 12 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL`ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ * +-100t , <br /> DISTANCE TO NEAREST: Septic Tank - Sewer Lines Pit Privy <br /> t Sewage Disposal Field — Cesspool/See page Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> }� INDUSTRIAL extraction ❑ CABLE TOOL Dia. of Well Excavation 1211 <br /> DOMESTIC/PRIVATE StandardD DRILLED Dia. of Well Casing 6 8" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 Steel <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 85, <br /> ❑ CATHODIC PROTECTION ffROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: C.12.rk <br /> PUMP INSTALLATION: Contractor C lark <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 <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shall not a ers ' such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring orb-contra sign ture rtifies the following:"I certify that in the performance of the work for which this <br /> permi is sued s a I plo ons bjec t workman's compensation laws of California." r <br /> I r r u1 I ori' io r g and a final inspection. <br /> Signed X Title: P— lark Well _ Date: A ril 2 1 8 <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASf I Cu1?7� <br /> Application Accepted By Date <br /> Additional Comments: C , <br /> hP:: I Gro I peciion a e III Final Inspection r - <br /> Mspection By OF (1�1 inspection By Dat <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 4 L43 ILU <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. gissuce Date f Mailed ,Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />