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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: <br /> APPLICATION <br /> i <br /> (For Non-Transferable, Revocable,Suspendable) <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 17631 S. Howland City/Town Lathrop <br /> f <br /> Owner's Name John R Mended Occidental Ch8mioal Co Phone 858-2511 <br /> Address 16777 Hari and City Laths <br /> Contractor's Name Clark Well & Equipment License# 371 560 Business Phone 462-5597 1 r <br /> Contractor's Address 2024 E. Charter Way Emergency Phone PITA j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ' No <br /> TYPE OF WORK (CHECK): NEW WELLU DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ S <br /> REPLACEMENT❑ in- Ag Field <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other I <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> PX INDUSTRIAL Monitor ❑ CABLE TOOL Dia. of Well Excavation n <br /> 91 DOMESTIC/PRIVATE 59andards❑ DRILLED Dia. of Well Casing 11 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 2.6 <br /> ❑ CATHODIC PROTECTION ID ROTARY Type of Grout sark mix <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I <br /> ❑ GEOPHYSICAL 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 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 /> Home owner 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 td 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 s r s subje to rkman's compensation laws of California." <br /> I w' r t I a on r' o gr ng an a final inspection. <br /> Date: 191111 <br /> Signed X Title: C 1 a T k y � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 � 7 <br /> Application Accepted By Date U — <br /> Additional Comments: <br /> has l Grout.inspectio Ph Ill Final Inspection 0 0 <br /> Inspection By Inspection By ! �at�%a/ 6 <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received B January 31 ❑ July t'&Vieceiy July 31 <br /> REMIT <br /> i BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> rAMOUNT <br /> �.3 yr <br /> k FEE 4 L <br /> r - <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br />! Received by Date Receipt No. Permit No. I+uancle Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 .STOCKTON,CA 95201 <br />