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mppnvauvns will me ressea wnen tiupmlttea Properly Completed. Be$u9 Sign The Application. r:..,vrrlCE USE: ? APPLICATION . (For Non-Transferable,Revocable,Suspendable) PUMP&WELL r _ ENVIRONMENTAL HEALTH PERMIT WATER (COMPLETE IN TRIPLICATE) QUALITY Application is hereby mal?tp the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is Ntiff made in compliance witfn Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 23709 East Brandt Road city/Town Lodi , Owner's Name .__Amoco_ Minerals Company Phone 303-761-5921 Address ,'1'33 West hamndan Ave-, Suita 500 _ City Eng god, C0 80.110 + Contractor's Name -Drilling Enierprises, Inc. License# Business Phone 307-234-4521 Contractor's Address Mills, Wyoming 82644 Emergency Phone _ Is Certificate of Workman's Compensation Insurance on Fiie With SJLHD? Yes No XX.— 1 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER M PUMP INSTALLATION ❑ PUMP REPAIR❑ v, 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____ 5 in-ch ❑ 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 n/a qj ❑ DISPOSAL ❑ OTHER Other Informationtest wean be abandoned upon KX EOPHYSICAL Surface Seal Installed By: COmb_lt?ti on PUMP INSTALLATION: Contractor w' Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done -- t . f. DESTRUCTION OF WELL: Well Diameter 6 inch — Approximate Depth 1 000 ft - Describe Material and Procedure F I 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:"l certify that in the performance of thework forwhich this h permit is issued, I shall employ persons subject to workman's compensation laws of California." I will II f r a u1 Inspection prior to grouting and a final inspection. j' Signed X Title: Project Geologist Date: October, 1980 l (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY � �� PHASE [ i Application Accepted By Date J1 i Additional Comments: r Phase tl Grout Inspection Phase III Final Inspection E Inspection By Date Inspection By Date .. ' Fee Is Due: ❑'ANNUALLY El PPR UNIT -0 PER SITE '❑ EACH ❑ January 1&Received By January31 ❑ July 1 &/Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED •, ` l 2 DATE DATE REMITTED AMOUNT FEE l J.�� 'i¢ �13(3 0 LESS l PRORATION PLUS PENALTY OTHER { OTHER Received by Dae Receipt No. Permit No. Issuance Date Mailed Delivered c) APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Boa 2009 STOCKTON, I