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ApplicationsWill Be ProcessedWhen Submitted Properly Compl Ind Bd:8ui"+eT6,SWhTheA`('pli� FOR OFFICE USE: APPLICATION �1 e3r� (For Non-Transferable, Revocable, Suspendablw U Y 1981 ENVIRONMENTAL HEALTH PERMIT PUMP&WELL SAN JOAQUIN LOCAL WATER QUALITY (COMPLETE IN TRIPLICATE) HEALTH O!STR!CT Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orinstail 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 Injection We 1 1 No. 1 City/Town Lathrop Owner's Name Occidental Chemical Company Phone 858-2511 Address 16777 So. Howland Road City-Lathrop CA___95330 Contractor's Name Eaton Drilling Company License# 1133783CS]business Phone 61 6-ti= Contractor's Address P-0 • Box 975,Wood 1 and, CA 9 5695 Emergency Phone _916-669-6795 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT[] . DISTANCE TO NEAREST: Septic Tank _ >500' Sewer Lines >, 0� Pit Privy >500'_ �J Sewage Disposal Field >, 0� Cesspool/Seepage Pit >500' Other >500' Property Line >SO0 Private Domestic Well>50 'Public Domestic Well>50 ' } INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 24 in/15 i n ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing 1 in/ in ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 in/3/16 in ❑ IRRIGATION ® GRAVEL PACK Depth of Grout Seal 290 f t. ❑ CATHODIC PROTECTION Ix7 ROTARY Type of Grout Neat cement grout IR DISPOSAL ❑ OTHER Other Information El GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Not Required Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done S 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 V' I.- ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner of 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 or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I wit' call tor,a Grout Inspection prior to grouting and a final inspection. Signed X , - Title: Luhdorff & Sca 1 ma n i n i , Date: 10/30/8) (Draw Plot Plan on Reverse Side) Consulting Engineers FOR DEPARTMENT USE ONLY f!"o PHASEIApplication Accepted By Date ` Additional Comments: Phase 11 Grout Inspection Phase Ili Final Inspection / Inspection By 42Date 'V\' ��7-6� Inspection By a ----Date Z_,,CAe r Fee 's Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED A M UNT FEE c. LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. ' 'Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21309 ,STDCKI`ON,CA 95201 .y