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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTrieAppllcaUOn. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 <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 <br /> 400 North of Louise & Howland City/Town Lathrop <br /> Owner's Name <br /> Occidental Chemical Co. Phone 858-2511 -16 <br /> Address 1 S . Howland City LathrO <br /> p T <br /> Contractor's Name Clark Well & Equipment License# 371-560 Business Phone 2-5597 <br /> Contractor's Address 2fl2 :.:.E. Charter Wa Emergency Phone NA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 1R DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 11 in open field <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 /> 12" <br /> ® INDUSTRIAL monitor 13CABLE TOOL pia. of Well Excavation <br /> 6 5 811 <br /> ® DOMESTIC/PRIVATEBtandard8❑ DRILLED Dia. of Well Casing 12 steel <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 1:1 IRRIGATION 1:1 GRAVEL PACK Depth of Grout Seal a rOX. 188* <br /> 1:1 CATHODIC PROTECTION X1 ROTARY Type of Grout sack mix <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 /> 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 /> Homeowner 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California." T <br /> Contractor's hiring or sub-contracting signature ce tifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, 1 shall p rs n subject workman's compensation laws of California." <br /> I wil r a r t n rio o nd a final inspection. <br /> Signed X Title: VP- lark. Well & ui Date: Nov•1,1980 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �Q- <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By � P-- Date Inspection By t. - <br /> Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT '❑ PER SIR ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> d <br /> Received by Date Receipt N. Permit No. Issua a Date Mailed delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON,CA 95201 <br />