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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT,EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 35000 S. CHRISMAN 'ROAD City TRACY Lot Size PM TRACY GOLF AND Owner's Name COUNTRY CLUB Address 35000 S CRRISMAN ROAD Phone 9,15-9890 Contractor NOACK PUMP .COMPANY Address 4500 E. FREMONT, STOCKTOficense N0.504513__ Phone • TYPE OF WELL/PUMP: t NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION IXX SYSTEM REPAIR ❑ OTHER ❑ ..* I �- DISTANCE TO NEAREST: SEPTIC TANK .,SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack„ El Tracy Type of Casing . Specifications L 1-1 Public ❑ Other F1 Delta Depth of Grout Seal y`r^ -� Type of Grout JX Irrigation --Approx. Depth I I Eastern s Surface Seal Installed by r� I TURBliP r NRepair Work Done ❑ Type of Pump TURBINE, "HRP. � State Work'Qone TNSTAI UMP � Well Destruction El Well Diameter Sealing Material (top 501 390- SETT!NG Depth Filler Material (Below 50) Q� �\ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I i DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet'.I Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms I iCharacter of-soil.to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TWe/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal I Distance to nearest: Welf Foundation Property Line ' LEACHING LINE 0 No. & Length of lines f. �" Total length/size E FILTER BED ❑ Distance to nearest: Well Foundation Property Line rQ a SEEPAGE PITS l 1 Depth Size '' Number . ' SUMPS C1 Distance to nearest. Well Foundation Property Line y f� DISPOSAL PONDS El tl 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San JoaquinLocal Health Di'etrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature t certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed x DICK TAYLOR Title; SALES/SERVICE, NOACK PUMP CO Date: 7 MARCH 1989 FOR DEPARTMENT USE ONLY Application Accepted by �cHcr"4!N Date — ZCL Area Pit or Grout Inspection by Z Date Final Inspection by to !o Additional Comments: ❑ Stk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 9 INFO CASH RECEIVE 13Y DATE PERMIT NO. �+-� r I/ +.EH 13-24 IREV.i/H 5) y� W EH 14-2e