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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APIPLICATION <br /> (For Non-Transferable , Revocable, Suspendable) i <br /> I PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WIATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtforla permitto construct and/or install the work herein described.This application is <br /> — E <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. i <br /> Exact Site Address 4 N LOLil. Lathrop <br /> S2 & MCklridlGy City/Town P <br /> Owner's Name Occidental Chemical Co Phone 858-2511 <br /> Address 1 777 S. Howland City Lathrop <br /> Contractor'sNameClark Well_& Equip License#371_.60 Business Phone 462-559 ; <br /> Contractor's Address 2,_Q24__. _ Emergency Phone NA. ) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ . RECONDITION❑ DESTRUCTION© !' <br /> WELL CHLORINATION ❑ WELLt_ABANOONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ kln.dustrial Monitor Well <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 /> ® INDUSTRIAL Monitor ❑ CABLE TOOL Dia. of Well Excavation 12" <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 811 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing # 12 Steel <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal app. 2001 <br /> ❑ CATHODIC PROTECTION 12 ROTARY Type of Grout 9 Sack mix sand cement <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ;' Surface Seal Installed By: <br /> I <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 /> Y R <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 3 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t <br /> Home owner 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 shal p oy a on in such manner as to become subject to workman's compensation laws of California." <br /> Contractor' ng T ub-contr Ign lure 911irtifles the following:"I certify that in the performance of the work for which this <br /> perm' i u sha I e per ns bje o workman's compensation laws of California." <br /> , <br /> I I for ro pe ion!`rio ro nd a final inspection. <br /> Signed X Title: VP-Clark Well & Equip Date: Feb• 11 ,1982 <br /> (Draw Plot Plan on Reverse Side) <br /> �R FOR DEPARTMENT USE ONLY <br /> PHASE I 11U. ( j p�,M Date <br /> Application Accepted By "Vti:� 0AIC" <br /> Additional Comments: <br /> Phase II Grout Inspection !vo+ Phase III Final Inspection <br /> Inspection By Date Inspection By e -1V-,�' r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> t BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT yy <br /> FEE O r <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> Received by Hate Receipt No. Permit No. Iss ante Ckafe Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 C, ' <br />