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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ) <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transierable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is i <br /> made in compliance with San Joaquin County Ordinance No.1$62 and the rules and regulations of the San Joauin Local Health District.- <br /> Exact Site Address 17631 S . Howland Site City/Town Lattro r <br /> Owner's Name Occidental Chemical Co on John Mendes DaWYne 858-2511 <br /> Addressi-6777 o land City Lathrop C� . <br /> Contractor's Name Clark Well & Equip._ License# 371560 Business Phone 462-5597 ) <br /> Contractor's Address 2024 E. Charter Way Emergency Phone NA, C <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No J <br /> TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ in A.g Field <br /> DISTANCE TO NEAREST: Septic Tank - Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other_ j <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ID INDUSTRIAL monitor ❑ CABLE TOOL Dia. of Well Excavation <br /> 211 <br /> ® DOMESTIC/PRIVATE sta.ndardSO DRILLED Dia. of Well Casing 578 <br /> It <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 Steel �'I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout 9—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 j <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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I s 11 loy per ons subject to workman's compensation laws of California." <br /> I <br /> I w' for Gr t on to ing and a final inspection. j <br /> Signed X Title: VP- CLARK WELL & EQUIP Date: May 13 ,1980 <br /> (Draw Plot Plan on Reverse Side) I <br /> FOR DEPARTMENT USE ONLY III <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection �jase III F nal nsp�c 1 n <br /> n <br /> Inspect" By C Date 1 a Inspection By C, Date d <br /> I�VQ <br /> tU <br /> Fee IS DUE: 11ANNUALLY ElPERU 7 El PER SITE 1:1EA H ❑ nuary 1 & ceived By anuary 31 y i & eceived By July 31 <br /> BILLING REMITTANCE $ REMIT y <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED +1J <br /> AMOUNT <br /> FEE 4 13 <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY ' <br /> OTHER <br /> I <br /> OTHER <br /> I <br /> a s6 <br /> Received by Date Receipt No Permit No. Issuan a Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />