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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> 1© PUMP&WALL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> t <br /> made in compliance with San Joaquin County Ordinance No.1862 andthe rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1'7631 South Howland Site #7 City/Town. Lathrop <br /> Owner's Name Occidental Chemical Company Phone 858-0251 r� f <br /> Address 1677'7 South Howland City Lathrop , <br /> Contractor's Name Clark Well & Eguip License# 371560 Busine s Phone 2`5597 f 1 <br /> Contractor's Address _2024 E Charter WayEmergency Phone N/A - 16-1 <br /> vv <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL50 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 11 in Ag Field <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 /> 12 INDUSTRIAL Monitor ❑ CABLE TOOL _ Dia. of WellExcavation <br /> 1211 t <br /> 15aDOMESTIC/PRIVATEStandard8 11 DRILLED' Dia. of Well Casing 6, 5/8tr <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ) 191 <br /> ❑ CATHODIC PROTECTION ® 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 <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. V <br /> �y <br /> Homeowner or licensed agent's signature certifies the following:A 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 /> permit is issued, I sha to ons su ct to workman's compensation laws of California." <br /> I will ca for r tins o p t ting and a final inspection. <br /> Signed X Tiile: VP Clark Well & Equip Date: 8 May 1980 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date CJ <br /> Additional Comments: <br /> Pha a out Inspection PhW III Final Inspection 3 �� I <br /> Inspection By` F Date Inspection By Date <br /> E ] <br /> Fee Is Due: ❑ ANNUALLY <br /> El UNIT © PER SITE ❑ EACH ❑ January 1 &Received By anuary 31 ❑ Su1y 1 Received y Ju 31 s <br /> $ REMIT <br /> BILLING REMITTANCE ] <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED fl <br /> AMOUNT g <br /> I <br /> FEE L 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S <br /> C_5`? [ E <br /> Received by Date Receipt No. Permit No. is uan a Date Mailed` Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZELTON Avg.'P.D.Boa 2009 STOCKTON,CA 95201 <br />