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1� 9 `1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLE PERMIT CALL (ZU`J) V0J-1bVf FOR INSPECTIONS LAPIK11=5 7 YEAR FROM DATE ISSUED JOB ADDRESS 9473 West Ln CITY/ZIPStockton --------------------------------- ------ --------- CROSS STREET_ Ronald_McNair Way �N-08406010 13 . 57 PARCEL SIZE LAND USE APPLICATION #____—__—__—_ OWNER NAME David _Butz1_Eg P10 er}IES LLL_-_- _---_--__ PHONE 209-652-3721 OWNERADDRESS 1620 North Carpenter Road, Bldg B CITY/STATE/ZIP Modesto, CA 95351-1153 CONTRACTOR ENC_ECZIP_c_QrpQCa#ed_—___------------ --------------- PHONE _925-719-0822- -- CONTRACTOR ADDRESS _�1�7/2+78 Golden_ Val ley Parkway _ _ CITY/STATE/ZIP Lathrop, CA 95330 SUBCONTRACTOR _Well oast EXp1 atiap--- PHONE 209_985-7541 ------- SUBCONTRACTOR ADDRESS _P_O_Box 133 —__ CITY/STATE/ZIP__Eu- LQn.-CA,-9-32-0—__—___—_ LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other__NUMBER _ 870761 EXPIRATION DATE— 1/ 3 1/ 2 0 2 4— DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) C Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water - -- --------------------------------- If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Monitoring Well(s) __ # of wells ❑ Soil Boring(s) —_--_ ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewa ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Other # of borings XI Geotechnical _8 I ❑ Cross -Connection Repair # of borings Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth__1G_311__ft Excavation _—C-- in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Sizein diameter ❑ Conductor Casing --- -- in diameter / Conductor Casing Depth Well Casing Diameter ____ in Thickness/Gauge/ASTM Sched❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other - Grout Seal Depth—LO Q___ft X Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cementsacl '0pffl9r ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall X Other Tremie ❑ Retardant / Accelerator (name) TMA PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other COUNTY ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick eNu11111N"1EN t in ❑ Christy Box ❑ Stove Pipe " PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MININIIIN7 24 HOUR ADVANCE NO -LICE REQUIRED FOR INSPE( I IONS - PLEASE CALL (209) 953-7697 _DEPARTMENT USE ONLY Application Accepted By — �� -- ----- Date Grout Inspection By Pump Inspection By Soil Boring Inspection By _f COMMENTS Date Date A.------ Date Area'3?A' 1`x I` -F'; ) Employee ID#_��L%%)'= ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE SC Received Check#/ Codes Info A B Cash Amount Date Permit/ Invoice # Well ID# Remittedervice u st # EHDO43-06 04/072022 Page 1 of 2 Welt / Pum Pennft