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Applications Will Be;Processed When Submitted Properly Completed. Be Sure To Sign The Application. .� FOR OFFICE USE: t APPLICATION "I f (For Non-Transferable, Revocable,Suspendable) • ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY j 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 made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District.1 i Exact Site Address Tank Farm Ox -hile S . Louise Mekinle}bty/Town Lathiro Owner's Name Occidental Chemical Company Phone 858-2511 Address 16777 S. _Howland City Lathrop + Contractor's Name Clark Well & Eguip License#371560 Business Phone 462-5597 Contractor's Address 2024 E. Charter Way_ Emergency Phone NA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �} ' TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 REPLACEMENT 11 near treatment ponds for use as monitor well 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 Z INDUSTRIAL monitor ❑ CABLE TOOL Dia. of Well Excavation 911 ' ❑ DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing 41 9 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Class 160 ❑ IRRIGATION 0 GRAVEL PACK Depth of Grout Seal a pp.- 40_1 ❑ CATHODIC PROTECTION ® ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information I ❑ GEOPHYSICAL I Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 0_State Work Done DESTRUCTION OF WELL: Well Diameter Approximate,Dept11 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. (' . Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I sha person subject to workman's compensation laws of California." I w' I for Gr I pr' r gro and a tiriai inspection. E Signed X Title: VP-Clark Well Date: . Jan 28 ,1982 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI z �� Application Accepted By Date I Additional Comments- Phase Phase II Grout Inspection j/o 6L�3 -4 Phase III Final Inspection Inspection Z L *T inspection By Date Inspection By Date 3 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT $ AMOUNT DUE CHECKED BASE EXPLANATION BILLING REMITTANCE i DATE DATE REMITTED AMOUNT F FEE ` C..ji- d LESS PRORATION PLUS ; PENALTY OTHER - OTHER ' Received by Date Receipt No, Permit No. tssuanc Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA-96201--""