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Applications Will Bi Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) E PUMP&WELL ENVIRONMENTAL HEALTH PERMIT s (COMPLETE IN TRIPLICATE) WATER QUALITY 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. Exact Site Address N. Louise & Mckinle City/Town Lathrop owner's Name Occidental Chemical CompanV Phone 858-2511Lathrop Address Howland City Contractor's Name Clark Well & Equipment License# 560 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 WELLEI DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT 11 Industrial monitor well I 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 M INDUSTRIAL monitor ❑ CABLE TOOL Dia. of Well Excavation 12 5481' 12 DOMESTIC/PRIVATE standard] DRILLED Dia. of Well Casing 6 5/811 ❑ DOMESTIC/PUBLIC E] DRIVEN DRIVEN Gauge of Casing t�` 12 Steel 3 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal app. 1401 ❑ CATHODIC PROTECTION E7 ROTARY 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 Describe Material and Procedure ' 1 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 emplo in such manner as to become subject to workman's compensation laws of California." Contractor's hiring r s b- racti n r certir the following:"I certify that in the performance of the work for which this permit is is ed, hal p y on ub' t to rkman's compensation laws of California." Y I w' r a s prio to a final inspection. Signed X Title:VP-C lark Well Date: Feb. 17 ,1982 ( raw Plot Plan on Reverse Side) PHASE I � FOR DEPARTMENT USE ONLY ry 'I Application Accepted By Date+ f Additional Comments: Phase 11 Grout Inspection 1IJj4o4-t4 vA, Phase III Final Inspection I Inspection By Date e44inspection By Date P Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 d BILLING REMITTANCE $ - REMIT BASE IEXPLANAT.ON DATE DATE REMITTED AMOUNT DUE CHECKED i AMOUNT FEE loll \\\ LESS i PRORATION { PLUS ! PENALTY OTHER OTHER SQA{ Received by Date _ Receipt No, Permit No. Issua ce Date Mailed Delivered - APPLICANT-RETURN ALL COPIES TO: -,.ENVIRONMENTAL HEALTH.PERM IT/SERVICES -1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201