My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
85-1491
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
C
>
COUNTRY CLUB
>
3635
>
4200/4300 - Liquid Waste/Water Well Permits
>
85-1491
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
8/23/2019 10:24:07 AM
Creation date
12/4/2017 8:42:38 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
85-1491
STREET_NUMBER
3635
STREET_NAME
COUNTRY CLUB
City
STOCKTON
SITE_LOCATION
3635 COUNTRY CLUB
RECEIVED_DATE
12/11/1985
P_LOCATION
EDWARD ZUCKERMAN
Supplemental fields
FilePath
\MIGRATIONS\C\COUNTRY CLUB\3635\85-1491.PDF
QuestysFileName
85-1491
QuestysRecordID
1705745
QuestysRecordType
12
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
2
PDF
View images
View plain text
, <br /> lG� <br /> APPLICATION FOR PERMIT - <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 3601 E. HAZELTON AVE., STOCKTON, CA <br /> t Telephone (209) 466-6781 <br /> PERMIT EXPIRES.1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 i <br /> made in compliance with San Joaquin County.Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 3635 CoMtry C1.Ub City Stockton Lot Size 95 x 192 PM <br /> EDWARD ZUCKERMAN 3635 Count=y Club <br /> Owner's Name Address - _ Phone <br /> TERRY JOY & ASSOC. 394241x.. Phone - 462-1481 <br /> t <br /> Contractor's Name License Na. r �t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ L!► <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL ____A OTHER WELL_ PITS/SUMPS <br /> INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial: ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q} <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ❑ Public ❑ Other { ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation $ ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done © Type of Pump H.P. State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION:9] DESTRUCTION ❑ (No septic,system permitted if public sewer is <br /> available within 200 feet./ <br /> Installation will serve: Residence .X Commercial Other , <br /> Number of living units: 1 Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth ; <br /> SEPTIC TANK ❑ Type/Mfg �' [S e-4^P Capaoity 0 Na. Compartments <br /> PKG, TREATMENT PLT, ❑ Method of Disposal ; <br /> Distance to nearest: Well Foundation Property Line a <br /> r <br /> LEACHING LINE 4 IJ No. & Length of lines one 'otal length/size 'nintY feet <br /> FILTER BED ❑ Distance to nearest: Well Foundation 12 Property Line 5 <br /> l <br /> SEEPAGE PITS I ❑ Depth Size Number i <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the Sen Joaquin Local Health District. <br /> 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 , <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:'1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> 4 The applicant must for all requ d inspections. Complete drawing on reverse side. 1 1 <br /> 14 <br /> Signed Title: Date: r a~ f <br /> FOR DEPARTMENT USE ONLY 'Q ` <br /> Application Accepted by I r l Date Js1 — f U Area / <br /> Pit or Grout Inspection by Data Final Inspection by LL(= �� Date L <br /> i Additional Comments: <br /> ❑ Stk 468-8781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 8364M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., 'P.O. Box 2009, Stk_, CA 55201 <br /> 4 <br /> FEE AMOUNT DUE AMOUNT REMITTED CAH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> a EH f3.24(REV.10/83) ��. • � 7Q � � ' p <br /> EH W28 - - - <br />
The URL can be used to link to this page
Your browser does not support the video tag.
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).