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s <br /> 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 /> f_A <br /> JOB ADDRESS 4946 W. Undine Road CITY/ZIP Stockton 95206 <br /> CROSS STREET W'AA2 APN 191-060-06 PARCEL SIZE 132.63 LAND USE APPLICATION# A <br /> m <br /> OWNER NAME Gallo Vineyards, Inc. PHONE(209)394-6200 H <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/ZIP <br /> LICENSE COC-57 O C-61 OD-09 Other NUMBER 745963 EXPIRATION DATE <br /> DoMEsnc WELL SAMPLING:_ General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)'L Arsenic(4393) <br /> INTENDED USE 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 Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bohng(s) a of borings Geotechnical u of borings <br /> D Out-Of-Service Well X Out-Of-Service Well Renewal 1:Cross-Connection Repair <br /> New Pum 7 Pump Replacement "I Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger i Cable Tool n Push Point Other <br /> Proposed Well Depth ft Excavation in diameter I Open Bottom I I Gravel Pack/Gravel Size in diameter <br /> i I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad I I Steel ❑Plastic i Stainless Steel f I Other <br /> Grout Seal Depth ft u Neat Cement(94 lb bag/5-10 gal water) I_I Sand Cement sack mix/7 gal water <br /> '!Bentonite(20%solids) Other <br /> Grout Placement Method _7 Pumped r l Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By C!Driller :I Pump Contractor ':I Other <br /> Concrete Pedestal:-Dimensions:Width ft Length ft Thick in 1 Christy Box i_Stove Pipe <br /> PUMP L 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 R VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)/953-7697 <br /> SIGNED TITLE Senior Director GVI-CV DATE <br /> loof <br /> T <br /> =te;91(W7W0 <br /> NT U E NLYApplication Accepted By Area Employee ID# {s�i(TJ <br /> 4&mW Inspection By Date (i' PECIAL Well Permit <br /> Pump Inspection By Date ! WAIVER Received <br /> Soil Boring InsppPCtion By -_---D'At Constructed Well Depth ft <br /> COMMENTS / F2'e— f og <br /> PE SC Received Check#/ Amount PermiU <br /> Codes Info Cash milted Date Service R uest# Invoice# Well ID# <br /> tflVjf3 d <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />