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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION I <br /> (For Non-Translerable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY j <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install thework 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 X31 South HowlandCity/Town Lathrop <br /> Owner's Name John Mendes/Occidental Chemical Co. Phone 858-2511 <br /> Address 167- S Howland c;ty Lathrop rI <br /> Contractor's Name Clark Well & Equip License# 3715 0 Busine s Phone 2-5597 W— { <br /> Contractor's Address 242 E Charter Wa Emergency Phone WA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ Near Dairy off Oxy Property <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 /> IN INDUSTRIAL Monitor 11CABLE TOOL Dia. of Well Excavation 20 i <br /> C n <br /> ® DOMESTIC/PRIVATE Standards DRILLED Dia. of Well Casing J 8 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing #12 <br /> ❑ IRRIGATION ❑ GRAVEL PACK V.Depth of Grout Seal 113' <br /> ❑ CATHODIC PROTECTION 13:ROTARY Type of Grout 9 Sack Mix <br /> ❑ DISPOSAL ❑ OTHER Other Information <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 S <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure r <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 /> 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's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> iwe%i <br /> subject to workman's compensation laws of California." <br /> gro n d a final inspection. <br /> Signed X Title: VP Clark Well & E_ quip Date: 5 May 1980 <br /> (Draw Plot flan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date (J v <br /> Additional Comments: <br /> ha Grput Inspection S rj b Phase III Final Inspection <br /> Inspection By ate O Inspection By , DAP I <br /> ate to <br /> I /1'n"� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S4TE ❑ EACH ❑ January 1 &Received By J nuary 31 ❑ Jul 1 &Receifed By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4 43 L-(3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> I OTHER <br /> S� sLT <br /> Received by Date Receipt No. Permit No. I suan a 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 />