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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. " FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT I (COMPLETE IN TRIPLICATE)`��(S l S hCGL�cfJL�E�° w�V _Q�aLITY Application is hereby made to the San Joaquin Local Health Distri>;t TOTa 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 Tank -Farm—Oxy loczati-On Q KCK! nley—Rf City/Town Lathrop I owner's Name Occidental Chemical Company Phone 8 j8 511 d Address 167'77 S . Howland City Za.thril Contractor's Name C lark�ni nt License# 5.6.0— Business Phone-4iT 7 Contractor's Address _2024 E.--C—h—arter Way Emergency Phone NA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL 0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �p WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ t DISTANCE TO NEAREST: Septic Tank n tank far5ewer�ln s t0 treatm�I."�yri'1Jonds �} Sewage Disposal Field Cesspool/Seepage Pit �Y Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ,, 0 INDUSTRIAL Monitor ❑ CABLE TOOL Dia. of Well Excavation9*1 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 40V ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 60 (� ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal app 401 ❑ CATHODIC PROTECTION ROTARY Type of Grout S ck 11 DISPOSAL DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. I PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done a DESTRUCTION OF WELL: Well Diameter Approximate Depth 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 1� ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner 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 ors "aturecefies the following:"I certify that in the performance of the work for which this permit is issue , I s mploy orkman's compensation laws of California."I fo rut I n pd a final inspection. I 3 Signed X Title: VP-Clark Well Date: -Jan-2—c,,19-B-2— (Draw Plot Plan on Reverse Side) I . I FOR DEPARTMENT USE ONLY ; PHASE r Application Accepted Date 1 Additional Comment Phase II Grout Inspection /vUf' f Phase 111 Final Inspection f Inspection By Date inspection By Date l f U— z_ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ 1 AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT 3 FEE ° � LESS PRORATION PLUS PENALTY ' OTHER OTHER Received by. Date Receipt No. Permit No. rssuancilif Date Mailed Delivered + APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STbCKTON,CA 95201 }