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,- s'r. "F Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION %, (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY 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 made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 763 S . Howland S it ee;,'_# 6 City/Town Lathrop Owner's Name Occidental Chemical Co Phone 858-2511 C� Address 17 601. S . Howland City Lathrop Contractors Name Clark Well & Eguip License#371. 60 Business Phone_ 462-5597 Contractor's Address 2024 E. -Charter Way Emergency Phone NA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT 13 near Gyp pond ! DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ® INDUSTRIAL monitor121' ❑ CABLE TOOL Dia. of Well Excavation EI DOMESTIC/PRIVATE standardEl DRILLED Dia, of Well Casing 6 81t ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing # 12 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 68' ❑ CATHODIC PROTECTION ROTARY Type of Grout 9 sack mix )� ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT. ❑ State Work Done_ PUMP REPAIR: ❑ State Work Done i DESTRUCTION OF WELL: Well Diameter Approximate Depth i Describe Material and Procedure P I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing:"I certify that in the performance of the work forwhich this permit 's issued, I sh mploy o s bject workman's compensation laws of California." I w' ora ro t In I rior o out' a d a final inspection. Signed X Title: VP-- Clark Well & Equi Date: May 19 ,1980 (Draw Plat Plan on Reverse Side) FOR DEPARTMENT USE ONLY I PHASEI Application Accepted By - Date 0 Additional Comments: Ph a II Grout Inspection P Ili Final Inspection Inspection By atp S `t.1d Inspection By ate � I Fee Is Due: ❑ ANNUALLY ❑ PtEU NIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received y Jul 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED rr DATE DATE REMITTED { AMOUNT FEE Loa) C� 4S '�}f t S LESS PRORATION PLUS PENALTY OTHER - a S OTHER y /' --qq •qq _ V �C7C� � A U Received by Date Receipt No. Permit No. Issuandig Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ..