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'? <br />I YPE VF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s)# of bodne s <br />X Geotechnical 3 #orbcnngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 15-25 ft Excavation 4-6 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 Steel Plastic Stainless Steel Other <br />Grout Seal Depth Full ft X Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL N/A Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED - TITLE President DATE 12/22/17 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inception By <br />RTMENT <br />Date <br />Date _ <br />Date <br />Date <br />Employee ID# <br />C' `SPECIAL Well Permit <br />WAIVER Received <br />Itructed Well Depth <br />ft <br />PE SC Received <br />Codes Info B Cash <br />P 0 <br />WELL/PUMP <br />PERMIT " <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 141 East Harney Lane <br />CITy/ZIP Lodi/95240 <br />CROSS STREET S. Stockton Street APN 062-410-35 <br />4--7k <br />PARCEL SR LANDUSE APPLICATION # <br />OWNER NAME DN PartnersLLC Z 7t,� &=% I5 ri--f nn <br />5 L[L PHONE 916-807-4073 <br />OWNER ADDRESS 10940 Trinity Parkway, C-274 <br />Applicant <br />CmISTnrE/ZIP Stockton/CA/95219 <br />CONMACTOR Korbmacher Engineering, Inc. <br />925.454.9033 <br />PHONE <br />CONTRACTOR ADDRESS 480 Preston Court, Suite B <br />Driller <br />CITY/STATE/ZIP Livennore,CA 94551 <br />SURCON'rRAt-rOR Cal Nev Geoexploration, Inc. <br />PHONE 916-778-0089 <br />SUBCONTRACTOR ADDRESS 1079 Sunrise Avenue, Suite B-339 <br />Roseville/CA/95661 <br />CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 768342 <br />)a EXPIRATION 09/30/2019 )kJIMR <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Townshl p Range Section_ <br />INTENDED USE DomestictPrivate Irrigation/Agricultural Industrial <br />_ <br />- Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different from Owner em me <br />Geotechnical Study <br />a ame or ono um er <br />I YPE VF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s)# of bodne s <br />X Geotechnical 3 #orbcnngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 15-25 ft Excavation 4-6 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 Steel Plastic Stainless Steel Other <br />Grout Seal Depth Full ft X Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL N/A Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED - TITLE President DATE 12/22/17 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inception By <br />RTMENT <br />Date <br />Date _ <br />Date <br />Date <br />Employee ID# <br />C' `SPECIAL Well Permit <br />WAIVER Received <br />Itructed Well Depth <br />ft <br />PE SC Received <br />Codes Info B Cash <br />Amount Perm iU <br />Remitted Date Service Re uest # Invoice # Well ID# <br />1177D <br />EMD 43.06 <br />crEntu'. <br />WELL PUMP PERMIT <br />T <br />g <br />NED <br />12013 <br />yWTH <br />