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WrrICE USE: a APPLICATION -* <br /> Non-Transferable, Revocable,Suspendabie) 4 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> - (COMPLETE IN TRIPLICATE} WATER QUALITY <br /> Application is hereby ma et the San Joaquin Local Health District for a permit to construct and/or install the workQQVT'hVipplicationis <br /> made in compliance wit an Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 23709 East Brandt Road City/Town Lodi <br /> t Owner's Name Amoco Mindrais Company Phone 303-761--5921 <br /> Address 333-West Hamprien Ave , Sali to 500_ _ City Englewood, CO 8011 <br /> Contractor's Name Drilling _.Enterprises,es, Inc.. License# Business Phone�307-234-4521 j <br /> Contractor's Address Emergency Phone <br /> k Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ACX c� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER XXX PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ exploratory test hole to be abandoned upon completion <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> N/A Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> k ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation 6 inch <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing none <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing node _ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal none �. <br /> ❑ CATHODIC PROTECTION XXX.ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> d�,EOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. IL <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 1 .000 ft <br /> Describe Material and Procedure •I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <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 forwhich'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." i <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 shall employ persons subject to workman's compensation laws of California." <br /> I will�stII f r a ut Inspection prior to grouting and a final inspection. <br /> Signed X Title: -RrDject Geologist Date: October. 1980 <br /> (Draw Plot Plan on Reverse Side) i <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY . <br /> j <br /> Application Accepted By Date <br /> Additional Comments: i; _ <br /> d <br /> Phase II Grout Inspection Phase III Final Inspection.., <br /> Inspection By Date Inspecte n ByDate <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> }� U DATE DATE REMITTED AMOUNT <br /> FEE43 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i I <br /> OTHER <br /> 1b at 10 5'31 d3 � <br /> Received by Da a Receipt No. Permit No Issuance Date Mailed Delivered <br /> —� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9$201 i <br />