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.I 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 /> t_n <br /> JOB ADDRESS 28750 N. Sowles Road CITY/ZIP Galt 95632 <br /> D <br /> CROSS STREET j N& APN 00711006 PARCEL SIZE 22_49 LAND USE APPLICATION# A <br /> m <br /> N <br /> OWNER NAME Gallo Vineyards, Inc. PHONE(209)394-620 n <br /> OWNER ADDRESS 5953 N. Weir Avenue CITY/STATE/ZIP Livingston,CA 95334 <br /> CONTRACTOR Don Pedro Pump PHONE (209)632-3161 <br /> CONTRACTOR ADDRESS PO Box 1038 CITYISTATE/ZIP Hughson CA95326 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 O C-61 O D-09 Other NUMBER 745963 EXPIRATION DATE <br /> DoMEsnc WELL SAMPLING:'__General Mineral/Coliform Bacteria(4391)'u Dibromochloropropane(4392), Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural : Industrial i Water Quality Monitoring li Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i'.New Well Li Replacement Well I i Well Alteration/Modification F: Other <br /> j Monitoring Wells) #of wells G Soil Boring(s) *of borings Geotechnical a of borings <br /> ❑Out-Of-Service Well X Out-Of-Service Wel Renew Cross-Connection Repair <br /> New Pum Pump Replacement "!Pump Repair ,,Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method :I Mud Rotary -1 Air Rotary n Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter FI Open Bottom a Gravel Pack/Gravel Size in diameter <br /> L'Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel G Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped 1 Free Fall 1 Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By _:Driller . Pump Contractor I Other <br /> Concrete Pedestal i_'Dimensions:Width ft Length ft Thick in L Christy Box Stove Pipe <br /> PUMP Submersible-Turbine -Other HP Pump Set ft Standing Water Level ft <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. I 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 /> MINIMU UR DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2091953-7697 <br /> SIGNED TITLE Senior Director GVI-CV DATE�� <br /> MENT <br /> EIVED <br /> 13 20.90 <br /> g UIN COUNTY <br /> NMENTAL <br /> EPARTMENT <br /> D A MENT USE ONLY <br /> a <br /> Application Accepted By ate l _A) Area Employee ID#.� <br /> Grout Inspection By A Date - PECIAL Well Permit <br /> Pump Inspection By �b�S \Qrn 2 c'tb4,, Date G 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Perm it/ <br /> Codes Info B Cash Remitted Date Service uest# Invoice# Well ID# <br /> FIX BE: 0 13 �{ <br /> EHD 4306 revised 4/14/18 WELL/PUMP PERMIT <br />