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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The-Application. <br /> FOR OFFICE USE: APPLICATION t <br /> „ (For Non-Transferable, Revocable Suspendable) PUMP&WEL� h' <br /> ENVIRONMENTAL'HEALTHPERMIT I' <br /> F (COMPLETE IN TRIPLICATE) f V7?-7 S, f_(L), JL.`-4�i/MATER QUALITY -0-5 . <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 /> f t wes tr of H f fi- south n City/Town <br /> Exact Site Address 600 <br /> Owner's'Name <br /> Occidental' Ghem i cal Company f Louise Ave phone„ 209-858-2511 - <br /> Address P.O. Box, 198 City Lathrop <br /> Contractor's Name Eaton Dri l 'l i ng Company License# 1 337$3-C578usiness Phone' 916-662-6795 <br /> Contractor's Address —P.0. BOX' 97$ +'Wood l and CA Emergency Phone Same as above' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No <br /> TYPE OF WORK (CHECK)-- NEW WELL DEEPEN ❑ .. RECONDITION❑' DESTRUCTION❑ �1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR { <br /> REPLACEMENT❑ 1 `� <br /> DISTANCE TO NEAREST: Septic Tank > 150 I Sewer Lines _ > 150, Pit Privy > 150' <br /> Sewage Disposal Field—> 1501 Cesspool/Seepage Pit > 150, Other > 1 000 f t. <br /> Prope�ty-.Line 100 fF4ivate Domestic Well-=? <br />