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Applications Will Be-Processed When Submitted ProperlyCompleted. Be SureTOsign ineApPnCallorl. \ <br /> FOR OFFICE USE: APPLICATION ` <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> mittoconstructand/orinstalfthewprk herein described.This application is <br /> Application is hereby made tothe San Joaquin Local Health Districtfora per <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1 mll �OLt1Se & MCkinle City/Town Lathrop <br /> Owner's Name "�cci n . l Chemical Company Phone 858-2511 a <br /> Address 16277 s .howlandCity—Lathrop <br /> Contractor's Name Clark Well & E ui men t License# 37156 Business Phone 462-5 97 <br /> ir jnTa�r enc Phone NONE <br /> Contractor's Address �-te Emergency y --� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 12 DEEPEN ❑ RECONDITION C1 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR i <br /> REPLACEMENT❑ lndustriasl monitor <br /> DISTANCE TO NEAREST: Septic Tank ewer Lines Pit Privy <br /> t Sewage Disposal Field Cesspool/Seepage Pit Other <br /> E Property Line 10 1 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 12" <br /> Q INDUSTRIAL Monitor El CABLE TOOL Dia. of Well Excavation <br /> 12 DOMESTIC/PRIVATE StandardO DRILLED Dia. of Well Casing 6 8rr <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 Steel <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal a-0p 4o m - <br /> ❑ CATHODIC PROTECTION JO ROTARY Type of Grout Sack mix sand Cement <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> l <br /> PUMP INSTALLATION: Contractor <br /> i.. 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 i <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> r <br /> Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this permit <br /> is issued, I shall note s in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hi in -contra si natur certifies the following:"I certify that in the performance of the work for which this <br /> per i ssu , I all p , e so ubj to workman's compensation laws of California." <br /> 1 <br /> to 1 1 In pr and a final inspection. <br /> signed X <br /> Title: VP-Clark Well & Equip• Date: Feb19 ,1982 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> {. PHASE I a �Z <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection 0 ho•f ,.f"' .44, Ahase III Final Inspection i <br /> 'l Inspection [3y <br /> Date a�vvfi {�f�� Inspection By Date <br /> r Fee IS DUB: ❑ ANNUALLY .❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> t REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> Y I <br /> FEE 3 <br /> LESS II <br /> PRORATION <br /> PLUS l <br /> PENALTY <br /> i OTHER <br /> t{ ; OTHER <br /> Received by Date rt i Receipt No. Permit No. lissuanckDale Mai12d Delivered 1 <br /> 16i)1 E.HAZELTON AVE.,P.O.'8ox 2609 STOCKTON�{A 95201 <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMITISERVICES - � <br />