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Tracy, CA 95304 CITY/STATE/ZIP <br />NUMBER 899451 ExPaRATioN DATE 6/30/2021 <br />UBCONTRA/CONSULTA <br />LICENSE <br />BILLING PARTY: OWNER CONTRACTOR <br />C-61 D-09 Other <br />Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />INTENDED USE <br />If different from Owner. Water System Name Contact Name or Phone Number <br />New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Well Alteration/Modification XOther Cone Penetrometer Test (CPT) <br />Soil Boring(s) 41Of borings XGeotechnical 1 # of borings <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />Pump Repair Raise Well Casing <br />A SI EE TE :DH AT— <br />84 <ee- <br />WELL /PUMP PERMIT END 43-06 6/11/2019 <br />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />Area sf irift Employee ID# A5 <br />SPECIAL ell Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />437a 150 .4 <br />lt, <br />(1/2sedi 41.i&I , 41117.4 1A)Fba1rr4 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date <br />Date 2-12.(/ 2- ll <br />Date <br />Date ft <br />TYPE OF WORK <br />JOB ADDRESS 1800 West Grant Line Road <br />Skylark Way <br />City of Tracy <br />OWNER ADDRESS 333 Civic Center Plaza <br />CONTRACTOR Middle Earth Geo Testing, Inc. <br />SUBCONTRACTOR/CONSULTANT BSK Associates <br />SUBCONTRACTOR/CONSULTANT ADDRESS 252 W. Larch Rd, Suite H <br />CROSS STREET <br />OWNER NAME <br />CONTRACTOR ADDRESS 23785 Cabot Blvd <br />CITY/STATE/ZIP <br /> PHONE 714-633-5025 <br /> CITY/STATE/ZIP Hayward, CA 94545 <br />PHONE 925-315-3151 <br />APN 232-020-03 <br />CITY/ZIP Tracy / 95376 <br />PARCEL SIZESt a (4 LAND USE APPLICATION # <br />PHONE 209-831-6000 <br />Tracy, CA 95376