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Out-Of-Service Well <br />New Pump <br />New Well Replacement Well Well Alteration/Modification \Other Cone Penetrometer Test (CPT) <br />Monitoring Well(s) #01 wells Soil Boring(s) # of borings XGeotechnical 1 # of borings <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />Pump Replacement Pump Repair Raise Well Casing <br />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />PHONE 714-633-5025 <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 />JOB ADDRESS 1035 East Grant Line Road CITY/ZIP Tracy / 95376 <br />CROSS STREET Skylark Way APN 213-07001R PARCEL SIZE 1. °S.. LAND USE APPLICATION # <br />OWNER NAME City of Tracy PHONE 209-831-6000 <br />OWNER ADDRESS 333 Civic Center Plaza cirdsTATErzip Tracy, CA 95376 <br />CONTRACTOR Middle Earth Geo Testing, Inc. <br />CONTRACTOR ADDRESS 23785 Cabot Blvd <br />SUBCONTRACTOR/CONSULTANT BSK Associates <br />crryisTATEmp Hayward, CA 94545 <br />PHONE 925-315-3151 <br />OWNER CONTRACTOR <br />C-61 D-09 Other NUMBER 899451 EXPIRATION DATE 6/30/2021 <br />WELL/PUMP PERMIT <br />SUBCONTRACTOR/CONSULTANT ADDRESS 252 W. Larch Rd, Suite H crryisTATErzip Tracy, CA 95304 <br />UBCONTRACCONSULTA <br />LICENSE <br />BILLING PARTY: <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 />2-0// /423 EHD 43-06 61110019 WELL /PUMP PERMIT <br />DEPARTMENT USE ONLY <br />Application Accepted By 41 .'n"...X/--- _ 2-- Date 0/10/141) Area CA/t c Employee ID# 4-5 <br />Grout Inspection By A. ,--0..\---.--- Date 11 Vol 2. 1 SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS 9) 0- wig CP I 1.1.Xik.er Ct V CI c*---krat 1oL.-.( culd 2'1z 411 u 1 1 ns of- ! ‘Jcuktr et( )call <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />Cash <br />Amount <br />Remitted <br />Permit/ <br />Service Rpquest # Invoice # Well ID# <br />tiva iso <br />dio <br />' #415-6 <br />patly.4 <br />2411 IATWit I laS <br />.. <br />ft <br />EE A A SI TE <br />__5ee <br />SA <br />TYPE OF WORK