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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 /> m <br /> JOB ADDRESS 4946 W. Undine Road CITY/ZIP Stockton 95206 m <br /> n <br /> CROSS STREET APN 191-060-06 PARCEL SIZE 132.63 LAND USE APPLICATION# O <br /> A <br /> m <br /> OWNER NAME Gallo Vineyards, Inc. PHONE(209)394-6200 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 CITY/STATE/ZIP Hughson,CA 95326 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE XC-57 ❑C-61 ❑D-09 Other NUMBER 745963 EXPIRATION DATE 3/31/19 <br /> DOMESTIC WELL SAMPUNG:0 General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ['.I Domestic/Private :Irrigation/Agricultural ❑Industrial Water Quality Monitoring 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 D Replacement Well ❑Well Alteration/Modification D Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) a of borings Geotechnical a of borings <br /> �J�ll 3 X Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary D Auger D Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom D Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix17 gal water <br /> D Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller D Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box D Stove Pipe <br /> PUMP _i 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 /> MINI OU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Senior Director GVI-CV DATE 2 $ <br /> EFNT <br /> IVSD <br /> z 8 2019 <br /> NME UN1Y <br /> IV <br /> PAR MENT <br /> DE ARTMENTUSE ONLY <br /> Application Accepted By A4, Date -1 Area (((/ Employee ID# `rt 16• <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Ins Dale WAIVER Received <br /> Soil Borin nspection B Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permiv Invoice# Well ID# <br /> Codeik Info B Cash Remitted Service Re uest# <br /> 21 t > <br /> EHD 4306 revised 4/14/18 WELL/PUMP PERMIT <br />