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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. _.,., uPFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELLJ (COMPLETE IN TRIPLICATE) WATER QUALITY n?,:?, /�� rte/ Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is ode in compliance with-San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. ct Site Address East Brandt Road City/Town Lodi Owner's Name Amoco Minerals C Dana Phone 303-761-5921 Address 333 West_Hampden_Ave. , Suite 500 City Englewood, CO 80110 Contractor's Name Drilling Enterprises, Inc. License ff Business Phone 307-234-4521 1 Contractor's Address Mills. Wyoming 82644 Emergency Phone same Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No __XX_ TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER XXX PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT 11 exploratory test hole to be abandoned upon completion DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy N/A Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ 6 inrh ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing none ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing none ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal none ❑ CATHODIC PROTECTION XXX ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Informationt-est wet to l]e abandon -d epo�� KMEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: 11State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter 6 inch Approximate Depth —1,000 ft Describe Material and Procedure neat cement 50 ft below surface;—cement cap t hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner 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 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." IwIIIlitr_a t Lit Inspection prior to grouting and a final inspection. Signed XT --- Title: Project Geologist Date: October_, 1980 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date�lJ! Additional Comments: V r Phase l! Grout inspection Phase III Final Inspection F 00 Inspection By Date Inspection By Date v P Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Ib��[ Q ,'3 � Received by Dae k Receipt No. Permit No. issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201