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wr-irICE USE: I APPLICATION / i '3or Non-Transferable, Revocable, Suspend able) r PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby maderfq the San Joaquin Local Health Districtfora permit to construct and/or install the work herein de crib Val lication is made in compliance wit an Joaquin County Ordinance No. 1862 and the rules and regulations of the San Jo i al Exact Site Address 23709 East Brandt Road ..city/Town Lod Owner's Name AMOCO Minerals Camey Phone 303-761-5921 Address 333 West Hampiden. Ave, Suitp 500 City EngIpwool, CO AMID_ Contractor's Name Drilling Enterprjses; Inc- License ff Business Phone 307-234-4521 1 Contractor's Address -Mills, Wyoming 8264A Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No XX TYPE OF WORK (CHECK): NEW WELL El DEEPEN 11RECONDITION ElDESTRUCTION❑ I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER XXX PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ 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 1 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 6 inch ❑ 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 —Ilia ❑ DISPOSAL ❑ _OTHER Other InformationtPSt�NPI1 to I1P ah,�`ndnner� I,psin (,a XXtEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor ! Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth I 00o ft Describe Material and Procedure _150 ft bt-]_nw surface; cement rap 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, -borne owner 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." I w111 111 r a ut Inspection prior to grouting and a final inspection. Signed �p Title; -Project Geologist Date. October, 1980 (Draw Plot Plan on Reverse Side) PHASE I FOR DEPARTMENT USE ONLY _ Application Accepted By ° Date Additional Comments: Phase It Grout Inspection Phase III Final Inspection Inspection By Date Inspection Byl-44 Dale r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ y REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT FEE 1S4J J* Z O LESS PRORATION I PLUS 1 PENALTY I OTHER OTHER d 1 � �t Received by - Date k Receipt No. Permit No. Issuance Dale - Mailed Delivered APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.;P.O.Box 2009 STOCRTON,CA 95201 �— e