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JOB ADDRESS <br /> O <br /> CROSS STREET Copperopolis Road APN 183-360-08 PARCEL SIZE I LAND USE APPLICATION# a <br /> m <br /> N <br /> OWNER NAME Joseph Martinez PHONE 707-483-4716 I LO <br /> OWNER ADDRESS 1804 Sherwood Court CITY/STATE/ZIP Santa Rosa, CA 95405 <br /> CONTRACTOR Delta Pump PHONE 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 X C-61 C D-09 ❑ Other NUMBER 724778 EXPIRATIONDATE 08/14 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE XXDomestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterizat;on <br /> 0 Public Water System <br /> If different from Owner: Water 6ystem Name uonlact Name or Flhone Number <br /> TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 0 Geotechnical #of borings <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump XXPump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> I <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point 0 Other <br /> I Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack rnix17 gal water <br /> ❑ Bentonite(20%solids) 0 Other <br /> (Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> Pur.^P XSubmersible❑ Turbine ❑ Other HP 1 Pump Set 182 ft Standing Water Level 135 ft i <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MINIMUM 24 HOUR ADVANCE NOTICE REOUII:ED FOR INSPECTIONS <br /> SIGNED — _ ar__�__!�. TITLE CEO DATE 03/18/14 <br /> MAP FORM <br /> N <br /> �'o 00�ropcl is 2-11 <br /> 112 i <br /> N <br /> ON <br /> EN <br /> EA TM 0 • Qo° a <br /> 3-3 <br /> EH� <br /> ASnron Koad j <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 7 2_1 / Area �1`i Employee ID# <br /> Grout Inspection Date SPECIAL Well Permit <br /> Pump Inspection Date :i 1'71 Ae WAIVER Received <br /> Soil Boring intspection 6 Date Constructed Well Depth __ft <br />