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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 /> Joe ADDRESS 4946 W. Undine Road CITY/ZIP Stockton 95206 <br /> D <br /> CROSS STREETAPN 191-060-06 PARCEL SIZE 132.63 LAND USE APPLICATION# z <br /> N <br /> OWNER NAME Gallo Vineyards, Inc. PHONE(209)394-6200 v <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 CA 95326 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE GOC-57 ❑C-61 ❑D-09 Other NUMBER 745963 ExPIRATION DATE 3/31/19 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well ❑Replacement Well D Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells D Soil Boring(s) #of bodnos #of barIngs <br /> ❑Geotechnical <br /> x Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> D New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑Alr Rotary D Auger ❑Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth ft Excavation In diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/610 gal wafer) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal DDlmenslons:Width ft Length ft Thick in D Christy Box ❑Stove Pipe <br /> PUMP ❑Submersiblec Turbine ❑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 OU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Senior Director GVI-CV DATE 2 g <br /> z s Zoos <br /> UIIV CO <br /> IJIV <br /> NME/V rMy <br /> Hill I <br /> PARTERT <br /> I #— <br /> DE ARTMENT USE ONLY <br /> Application Accepted By Dale Area Employee ID# <br /> Grout Inspection ByDate ❑ SPECIAL Well Permit <br /> Pump Inspection By n Dale 0 WAIVER Received / <br /> Soil Boring Ins ecllon By Dale onstructed Well De th <br /> e <br /> COMMENTS )11A I <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# CCCJJJ <br /> Code Info B Cash Remitted Service-Request <br /> 2l J <br /> END 43-06—1,.d 4/14/18 �.�. S 1-�U I`n , ✓/ L I S+"-`I a-�R Ul;Y7T V wELL/PUMP PERMIT <br /> W:�T i in <br />