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maybe vveu <br />Drilling Method XMud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 650 ft Excavation 19 in diameter Open Bottom XGravei Pack/Gravel Size 3/8 in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter 12 in Thickness/Gauge/ASTM Schad 28(1 X Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 k Neat Cement (94 lb bag/5-10 gal water) )(Sand Cement 10.3 sk sand Sluurgack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method XPumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller X Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />P Submersible Turbine Other HP Pump Set itStanding Water Level ft <br />EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />LI 1,N4WUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />R IWD ACTIVE WITH THE ,CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />0 MPENSATION LAWS. <br />INIMUM 24 HOU NCE j{�'fl IRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />�js Q o , t TITLE President DATE 01/26/2016 <br />l <br />y <br />1 <br />pAY <br />EIVE® <br />01 2015 <br />TAL HEALTH <br />.-RVICES <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Grout Inspection By <br />JOB ADDRESS 19730 E. Coyote Creek Lane CITY/ZIP Clements. CA 95227 <br />Date SPECIAL <br />CROSS STREET N. Macville RD APN 009-190-26 PARCEL SIZE 80 LAND USE APPLICATION # <br />Pump Inspection By <br />OWNER NAME Lupe Benito PHONE agent (916)743-7872 <br />Date WAIVER Received <br />Go 2125 W Capitol Rd West Sacramento. Ca <br />OWNER ADDRESS P CITYlSTATE/ZIP <br />CONTRACTOR One Source Drilling & Pumps PHONE (925) 785-2015 <br />CONTRACTOR ADDRESS 3494 Camino Tassajara # 227 CITY/STATEMP Danville. Ca 94506 <br />ft <br />SUBCONTRACTOR PHONE <br />f <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 1002672 EXPIRATION DATE 04/2017 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range - Section_ <br />INTENDED USE Domestic/Private X Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Chec ! Amou <br />Cash Remitted <br />Public Water System <br />Well ID# <br />If different from Owner: Water System Name Contaot Name or Phone Number <br />TYPE OF WORK X New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWell(s) #of wells SoilBoring(s) #ofborings Geotechnical #ofbormp <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />maybe vveu <br />Drilling Method XMud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 650 ft Excavation 19 in diameter Open Bottom XGravei Pack/Gravel Size 3/8 in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter 12 in Thickness/Gauge/ASTM Schad 28(1 X Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 k Neat Cement (94 lb bag/5-10 gal water) )(Sand Cement 10.3 sk sand Sluurgack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method XPumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller X Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />P Submersible Turbine Other HP Pump Set itStanding Water Level ft <br />EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />LI 1,N4WUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />R IWD ACTIVE WITH THE ,CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />0 MPENSATION LAWS. <br />INIMUM 24 HOU NCE j{�'fl IRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />�js Q o , t TITLE President DATE 01/26/2016 <br />l <br />y <br />1 <br />pAY <br />EIVE® <br />01 2015 <br />TAL HEALTH <br />.-RVICES <br />EHD 43-06 <br />_ <br />ID# l <br />Application Accepted By <br />DEPARTMENT SE ONLY `*-I <br />Date Z Area / k Employee <br />Grout Inspection By <br />Date SPECIAL <br />ell Permit <br />Pump Inspection By <br />Date WAIVER Received <br />Soil Boring Ins actio <br />Date Constru ted Well D pth <br />ft <br />�By <br />COMMENTS L <br />f <br />PE SC Received <br />Codes Info B <br />Chec ! Amou <br />Cash Remitted <br />Permit/ <br />Date Service Request # invoice # <br />Well ID# <br />f13A I l �g> l/,4- <br />ri sca— I -56A <br />-K-16 SA i 11204 <br />T <br />EHD 43-06 <br />