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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application,Y <br /> FOR OFFICE USE: APPLICATION <br /> (For.Non-Transferable, Revocable, Suspendable) <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 S n Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address 17631 South Howland City/Town Lathrop <br /> owner's Name John Mendes/Occidental Chemical Co. Phone 858-2511 <br /> Address '777 South Howland city Lathro-P a <br /> Contractor's Name Clark Well & Equip License# 371560 Business Phone 462 _ <br /> Contractor's Address 202 E Charter Way Emergency Phone NIA_ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No i <br /> TYPE OF WORT( (CHECK): NEW WELL 12 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ .�, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Near Dairy off Oxy Property J <br /> DISTANCE TO NEAREST: Septic Tank Sewer 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 /> M INDUSTRIAL Monitor ❑ CABLE TOOL Dia. of Well Excavation . 1211 <br /> DOMESTIC/PRIVATES tandards❑ DRILLED Dia. of Well Casing 5 8n <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing #12 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1781 <br /> ❑ CATHODIC PROTECTION 6 ROTARY Type of Grout 9 Sack Mix �N <br /> ❑ DISPOSAL ❑ OTHER Other Information r-- <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 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 sha toy p s s bject t ork a a compensation laws of California." <br /> I wi or r u I t, for uti a final inspection. <br /> Signed X Title: VP Clark Well & Equip Date: _ 6 May 1980 <br /> .1114'. w Plot Plan on Reverse Side) — <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By. L Date u v <br /> Additional Comments: <br /> "IlGrout Inspection `r P III Final Inspection t7 <br /> Inspection By Date r b Inspection By Date -3 d M <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By nu ary 31 ❑ J uly 1 &Re ived 6y Juiy 31 <br /> BILLING REMITTANCE REMIT <br /> BASE - EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ## <br /> PLUS 1 <br /> PENALTY € <br /> OTHER <br /> 1 <br /> OTHER <br /> _ 0 SE'S` <br /> Received by _ Date Receipt No. Permit No. IdsuancL 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 />