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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 /> N <br /> JOB ADDRESS 28750 N. Sowles Road CITY/ZIP Galt 95632 m <br /> Q��� a <br /> CROSS STREET 111 09 I�l f APN 00711007 PARCEL SIZE 131.39 LAND USE APPLICATION# A <br /> m <br /> N <br /> OWNER NAME Gallo Vineyards, Inc. PHONE(209)394-6200 <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 CITY/STATE/ZIP Hughson CA95326 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE D X C-57 O C-61 ❑D-09 Othef NUMBER 745963 EXPIRATION DATE <br /> DoMESTIC WELL SAMPLING:_I General Mineral/Coliform Bacteria(4391) i Dibromochloropropane(4392)[I Arsenic(4393) <br /> INTENDED USE i_.Domestic/Private i Irrigation/Agricultural Ci Industrial i.!Water Quality Monitoring U Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of bodngs Geotechnical #of bodngs <br /> ❑Out-Of-Service Well X Out-Of-Service Well Renewal 11 Cross-Connection Repair <br /> f,New Pump Pump Replacement a Pump Repair :Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary ❑Auger Cable Tool D Push Point -� Other <br /> Proposed Well Depth ft Excavation in diameter _'Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched U Steel ,i Plastic i5 Stainless Steel i Other <br /> Grout Seal Depth ft i i Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> i1 Bentonite(20%solids) C: Other <br /> Grout Placement Method Pumped :Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _;Driller Pump Contractor '. Other <br /> Concrete Pedestal _;Dimensions:Width fl Length ft Thick in i Christy Box U Stove Pipe <br /> PUMP Submersible_:Turbine 1 Other HP Pump Set It 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 /> MINI UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(20953- 697 <br /> SIGNED TITLE Senior Director GVI-CV DATE ) �� <br /> YMA '7 <br /> ENT <br /> 1111 iVED <br /> 11 EER 3 2020 <br /> N COUNTY <br /> ENTAL <br /> ' _ ARTMENT <br /> A MENT SE N L Y <br /> _gXip <br /> Application Accepted By a Area Employee ID#_� <br /> Grout Inspection By ( Date PECIAL Well Permit <br /> Pump Inspection By Clltnc.S\a ' Date �0 (1�`Lsi WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/Codes Info Cash emitted Date Service Re uest# Invoice# Well ID# <br /> 2 2 <br /> EHD 43-06 revised 4114/18 WELL/PUMP PERMIT <br />