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JOB ADDRESS 37.593194, —121.338583 S-S17 0 &c,ffery crryizip N/A, 95377 <br />77 acres CRossSTREETGaffery Road & 5 FWY ApN 26526002 PARCEL SIZE <br />OWNER NAME Crimson California Pipeline, L.P. PHONE 562-285-4112 <br />OWNER ADDRESS 3760 Kilroy Airport Way, Suite 300 <br />CITY/STATE/ZIP Long Beach, CA, 90806 <br />CONTRACTOR Crimson Midstream, LLC <br />PHONE <br />CONTRACTOR A00RE553760 Kilroy Airport Way, Suite 300 CITY/STATE/ZIP Long Beach, CA, 90806 <br />SUBCONTRACTOR/CONSULTANT ABC Liovin Drilling, Inc. PHONE 562-981-8575 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1180 E Burnett St. CITWSTATE/ZiP Signal Hill, CA, 90755 <br />LICENSE X C-57 C-61 D-09 Other NUMBER 422904 EXPIRATION DATE 09/30/2022 <br />BILLING PARTY: OWNER X CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />LAND USE APPLICATION # N/A <br />Well Alteration/Modification x Other Cathodic Protection <br />Soil Boring(s) <br />Out-Of-Service Well Renewal <br />Pump Repair <br />Geotechnical <br />Cross-Connection Repair <br />Raise Well Casing <br /># of borings # of borings <br />PA Ym <br />PEC E/VE t) <br />EISIA,J°4 ')U co ot , HEAL Tri'verAmpNr4i: <br />R TIVIF <br />re Cs APR 0 8 2021 <br />Ty <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.Sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE X Demettic/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 :SS31:1a0V 311S New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />TYPE OF WORK <br />WELL CONSTRUCTION <br />Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 500 ft Excavation 10 in diameter Open Bottom Gravel Pack/Gravel Size N/A in diameter <br />Conductor Casing N/A in diameter / Conductor Casing Depth N/A ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50' ft x Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped Free Fall <br /> <br />Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />x Concrete Pedestal Dimensions: Width 2 ft Length 2 ft Thick 12 in Christy Box Stove Pipe <br />PUMP N/A 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 42- TITLE Ivan Liovin — President DATE 4/7/2021 <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By — Date 4111r /ii Area Employee ID# <br />Grout Inspection By qtalatkii% Date LOZA(ZA <br /> <br />SPECIAL Well Permit <br /> <br />Pump Inspection By Date <br /> WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS \ 'L.>) jsylc . A/ t4i1 I G t/tel b.) r t-40 . M <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ Amount Permit/ <br /># Invoice # Well ID# £13 7 1 1 g 1 (ix ex jr_t_ ,peinaitted DT Li.ls al te4ervitice. pat <br />EHD 43-06 6/11/2019 eja /23 `P1-816,3 WELL /PUMP PERMIT