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f Applications-Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: Y y APPLICATION K x °- (For Non-Transferable, Revocable, Suspendable) PUMP&WELL E ENVIRONMENTAL HEALTH PERMIT ` (COMPLETE IN TRIPLICATE) r 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. 1882 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Oxy Tank Farm-1 mile S. Louise MCkinlegty/Towr/__L throp -"Owner's Name Occidental Chemical Company Phone 858-251-1 Address 16777 S. Howland City T.a.thr_o , i Contractor's Name Clark Well & Equipment License# 60 Business Phone 46�� 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 WELLM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ treatment pond monitor Well-nextto 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 1:1 CABLE TOOL Dia. of Well Excavation 9'� I ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 41v ' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Class 160 ' ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal app. 402 ❑ CATHODIC PROTECTION KIXROTARY Type of Grout 9 sack mix-Sand/Cement ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ! ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth CDescribe Material and Procedure i 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:"1 certity 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 CaMornia." Contractor's hiring It c ' g signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I I em er ns su ject to workman's compensation laws of California." 1 W9a o esti In p ' to uting and a final inspection. k Signed X Title: Vilark Well Date: n. 8 I (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE 1 F Application Accepted By— j til rE �- Date k Additional Comments: Phase it Grout Inspection AA+ ase C�Iced ✓� P III Final InspectionDate tion . yYv✓i +fin j/'' !O,2 I _y--+._ Inspection By Date Inspection Bim/ _ Fee Is Due: 11 ANNUALLY ❑ PER UNIT El PER SITE 11 EACH 11 January 1 &Received By.January 31 ❑ July 1 &Heceived By July 31 REMIT BASE - EXPLANATION BILLING REWTTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT N o !N FEE 3 LESS PRORATION PLUS PENALTY OTHER F OTHER A Received by Date Receipt No. Permit No. lissuancd Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMINSERVICES 1601 E.HAZELTON AVE.,P.O.Box.2009 STOCKTON,CA 9520f'