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SR0079500
Environmental Health - Public
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12 (STATE ROUTE 12)
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4200/4300 - Liquid Waste/Water Well Permits
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SR0079500
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Last modified
11/19/2024 3:48:03 PM
Creation date
9/11/2018 4:20:41 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0079500
PE
4222
STREET_NUMBER
7101
Direction
E
STREET_NAME
STATE ROUTE 12
City
LODI
Zip
95240
APN
04913052
ENTERED_DATE
8/10/2018 12:00:00 AM
SITE_LOCATION
7101 E HWY 12
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />NON-KEFUNDABLE PERMIT GALL (ZUW &0J -/DY/ FUR INSPtG11UNS <br />JOB ADDRESS 7101 E State Route 12 CITy/ZIP Lodi / 95240 <br />CROSS STREET Tecklenberg Road APN 049-130-52 & 54 <br />OWNER NAME Nhon Tan Vlen <br />PARCEL SIZE 115.3+/- Acres <br />209-482-3679 <br />OWNER ADDRESS 16160 N. Moore Road CITY/STATE/ZIP Lodi/Ca/95240 <br />CONTRACTOR Dillon & Murphy PHONE 209-334-6613 <br />CONTRACTOR ADDRESS P.O. Box 2180 CITY/STATE/ZIP Lodi/CA/95240 <br />LICENSE 'I. C-42 ❑LIC -36 OTHER NUMBER EXPIRATION <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST #'- <br />BUILDING PERMIT # <br />LAND USE APPLICATION #PA 1600024 <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED /ALTERNATIVE <br />ft FOUNDATION <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />F1 COMMERCIAL <br />OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPEIMFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ MOUNDED <br />DISTANCE TO NEAREST: WELL <br />it FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES it <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE it <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE R <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />It DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <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 />SIGNED <br />F7 // <br />PARCEL 2 .9 N.AAD T.S. „yNp <br />:in ' F Mns�'(u) MrsN(MI v.nsr(NI <br />2,P Application Accepted B <br />g Final Inspection By <br />g <br />S 0 Character of Soil to <br />COMMENTS <br />m. s s.anm. <br />WIT IfVar-Cl, I IV/VQ - r-LC/HJC l.01LL IZUyI VUJ-IUWI <br />TITLE Party Chief DATE dw- / G _ �CI <br />".-M) I -' ..RTMENT USE O Y <br />Date - O i c7 Area Employee ID# <br />14 Date 2- 2- Y C3 SPECIAL PERMIT - Approved by <br />th Ft• PIUSump Soil C^h�aracte�r* ,7 <br />PE Sc Received Check#/ Amount Date Permit/ Invoice # Permit ID# <br />i�W Y 17 <br />Code INFO B Cash Remitted Service Request # <br />-222 . <br />4-z Q' <br />44.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />
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