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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> /f <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 1 <br /> i1�_S: off' ouise & MckinleV City/Town Lathrop <br /> Owner's Name OcCid ental Chumi_cal CO. Phone 858-2511 <br /> Address 1-67-Z7_S_. How . city_ La hro <br /> Contractor's NameClark Wall_ c�Fqulp n License#321_5-60 Business Phone 62- 59� �- <br /> v <br /> Contractor's Address 2.024 E—Charfe Emergency Phone NA ��- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL_Q DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION © PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Test HOleSewer Lines open f le�"CZ 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 61 <br /> ' <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 -sack mix <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor --1 <br /> Type of Pump H.P. _J <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 61 Approximate Depth 3201 <br /> Describe Material and Procedure fill in to - 0' with sand, sack <br /> mix to to-P. <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 /> F is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title. VP-Clark Well Date: Aug24,1.981 <br /> (Draw Plot Plan on Reverse Side) <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ��/ _._ Date Z .;k t-yl <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phas NI Final Inspection r � <br /> Inspection By Dated Inspection By Date 11e� o�g� <br /> Fee Is due: El ANNUALLY 4 ❑ PER UNIT ❑ PER' SITEA" LTEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ` L4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uance to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />