80-430 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFIC 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 for a 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 Joauin oCal Health District. Exact Site Address 17631 S . Howland City/Town �rat�rop Owner's Name Occidental Chemical Co. Phone 858-2511 Address 1 7b 1 S . Howland City Lathrop Contractor's Name Clark Well & Equip License# 3715 0 Business Phone 2--5597 Contractor's Address 202 E. Charter Way Emergency Phone NA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ near Chem 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 monitor ❑ CABLE TOOL _ Dia. of Well Excavation " M DOMESTIC/PRIVATEGtandard8 11DRILLED Dia. of Well Casing 5 81' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 186* ❑ CATHODIC PROTECTION ® ROTARY Type of Grout 9 Sack mix 4 ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor J Type of Pump H p PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done - DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 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 thework for which this permit is issued, I shall note n person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring sub-contract sig lure certifies the following:"I certify that in the performance of the work for which this perm is i sued, I sh II p y s bject to rk an's compensation laws of California." I I for a ro 1 s 6 riot it t o a inal inspection. -4 Signed X Title: Clark Well & Equip Date: May 22 ,1 80 (Draw Plan on Reverse Side) USE ONLY PHASE I Application Accepted By F�DDEPARTMENTDate 3--m—SO Additional Comments: Phase II Grout Inspection ha III Final Inspection �-:33e Inspection By Date Inspection By ate w+ SPFRNIT _ C. rFee is Due: ANNUA ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By J uary 31 ❑ July 1&Red By Aly BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE REMITTED AMOUNT DUE CHECKED •DATE FEE AMOUNT .� y� � LESS PRORATION PLUS PENALTY OTHER OTHER F Received by Date Receipt No.- Permit No. Issuance Date Marled Delivered ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201