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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FQ�,4 OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendablle) <br /> 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 17 31 S . Howland City/Town Lathrop <br /> Owner's Name onq MendesZOccidental Chemical. Co Phone 858-2511 <br /> Address . 16777 S .Howland City Lathrop <br /> Contractor's Name Clark Well & Equl� License#371560 Business Phone '�) 2-5597 w <br /> Contractor's Address 2024 E. Charter ay Emergency Phone NA. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No —Q <br /> TYPE OF WORK (CHECK): NEW WELLID DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 11 near Dairyoff Oxy roperty <br /> DISTANCE TO NEAREST: Septic Tank ewer 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 /> 1XINDUSTRIAL Monitor ❑ CABLE TOOL Dia. of Well Excavation 1211 <br /> ZI DOMESTIC/PRIVATE standards❑ DRILLED Dia. of Well Casing <br /> ❑"DOMESTIC/PUBLIC [3-DRIVEN- Gauge of Casing •-1.2 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5 <br /> 111 <br /> 11CATHODIC PROTECTION ® ROTARY Type of Grout 9 sack mix <br /> ❑ DISPOSAL ❑ OTHER Other Information crS <br /> ❑ GEOPHYSICAL A Surface Seal Installed By: <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 e - 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 �y <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 for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor' ring or su - ontracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is is a .I shall a plo ersons ubject to workman's compensation laws of California." i <br /> I call o G u s ct' for routing and a final inspection. f <br /> I <br /> Signed X I Title: VP Clark Date: May 2 ,1980 <br /> (Draw Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE.1 �Md <br /> Application Accepted By DateT;� <br /> b <br /> Additional Comments:. <br /> Ph 11 Grout Inspection Ph a III Final Inspection <br /> Inspection By S a g--Inspection By ate ` <br /> Fee ISO—e: 11:11ANNUALLY : El PER UNIT El PER SITE El EACH El January 1 &Received By Jan ary 31 July 1 &Received BJ1 <br /> REMIT <br /> BILLING. REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED. AMOUNT DUE CHECKED - <br /> AMOUNT <br /> FEE 4 'f `t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> Received by Date '.Receipt No. Permit No i Iss ante Date Mailed Delivered - 1 <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20119 STOCKTON,CA 95201 <br />