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SR0073807
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4200/4300 - Liquid Waste/Water Well Permits
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SR0073807
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Last modified
3/2/2021 2:39:38 PM
Creation date
3/2/2021 2:34:23 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0073807
PE
4210
STREET_NUMBER
3644
STREET_NAME
COUNTRY CLUB
City
STOCKTON
Zip
95204
APN
12103004
ENTERED_DATE
12/4/2015 12:00:00 AM
SITE_LOCATION
3644 COUNTRY CLUB
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
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EHD - Public
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ONSITE WASTEWATER 14-11E•ATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS �1 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S (04fVN7,�c.�� 1 d i3L- t <br /> _ CITY/ZIP v ��� LA '5--U A IF L <br /> �^ 4 n rye --q <br /> CROSS STREET ! [E!Q �I/I .,►[ff APN _©3y 1 PARCEL SIZE 0-J0 p <br /> OWNER NAME G' iCX\k. �lJl/1�11LO – C'1 L / <br /> )/eM{T I��� (I>J�V. IIIc. PHONE ' Z ��� �jZ S <br /> OWNER ADDRESS �"' ` �/�1�1��—U✓"J RL, CITY/STATE/ZIP CA cff� 1L/ <br /> CONTRACTOR _ PHONE <br /> CONTRACTOR ADDRESS _CITY/STATE/ZIP <br /> LICENSE 11 C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> L] PERC TEST # BUILDING PERMIT# _ __- LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE 11COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG kcS&t5T?Ntr _ CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS. #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH Zo ft LENGTH 2O ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION O ERT ` '' �'� ft <br /> El SUMPS WIDTH _ ft LENGTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ftV 1 nave exPired without _ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 11,A being Dom es f)r inc n�a�+.1, ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH by rift r-• ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE-' j ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED TITLE ���ai1� DATE —,L( ( I5� <br /> z Z <br /> LU <br /> UZQ <br /> -- - - Asa <br /> - - -- ata <br /> aux <br /> LLJ �W� <br /> a LU <br /> to � 4 <br /> -Pam. S- ,t N <br /> T=77==__ <br /> DCPA^T84ENT USE 011JI1. Y 3 <br /> Application Accepted By Date-- ----- Area % Employee ID# ES GO ZTa <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: _ Pit/Sump Soil Character: <br /> COMMENTS C)L.,J ", 7OF /P_4F_C_,0 0 . A-.dJrt-)G- frac 8£JA14ym '%D ,e<2crSTz Diu i.v��-- <br /> - -..._....--- <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> O (s - <br /> 2 � � J <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />
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