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83-1321
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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83-1321
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Entry Properties
Last modified
8/3/2019 11:19:15 PM
Creation date
12/4/2017 7:46:49 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
83-1321
STREET_NUMBER
53 & 101
Direction
S
STREET_NAME
COOLIDGE
City
STOCKTON
SITE_LOCATION
53 & 101 S COOLIDGE
RECEIVED_DATE
12/02/1983
P_LOCATION
PIERCE
Supplemental fields
FilePath
\MIGRATIONS\C\COOLIDGE\53\83-1321.PDF
QuestysFileName
83-1321
QuestysRecordID
1699562
QuestysRecordType
12
Tags
EHD - Public
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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocable•, and Suspendable) SEPTAeGE > <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> LIQUIb WASTE <br /> Applica�Iebcarry on businessin the jurisdictional area of the San Joaquin Local Health Districtr Business Name D$A] Address`— 2i Owner b,bAddress,- <br /> 2 <br /> ddress 2 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.. �. t! Y, Emergency Telephone No.j <br /> Contractor Licence No. _ <br /> Applicants Name (!Tint) Title : G,. :` Date- <br /> Please check Applicable Category.(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �- <br /> For July 1,—'--: June 30, 19 "=W' Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> -Capacity Gal.,Weights& Measures No. <br /> Equipment Parking Address <br /> t <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST t.- <br /> P.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time 1 ' <br /> j <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Nc^ c-.Q_ 0-L-k-1 Address f <br /> ❑ SEPTIC TANK-0 CESSPOOL `❑ LEACHING FIELD ®"3E PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑3NEW w ❑ REPAIR x ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units .Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certif led . <br /> Plant Location <br /> yPlant Capacity No. Units Served <br /> -- <br /> 7. ❑ LAUNDRY For July 1, -June 30, 190 <br /> ;SIZE: 0 Less Than 1,000 Sq: Ft., ❑ More Than 1,000 Sq. Ft. f <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Homeownororiicensedana-rtt`ssignatareC2�afiastrio tnrovi'-ng:"Ic-arti'y'hil;nth�performanccn thr.-kamrkfc!,%vhichthispormnti9issuad,IshMInater'plaY any person <br /> if,such marinei as to become sttbject to cempi rise nEi Id!+r5 lit C lii�J7s.i, . <br /> Contractor's hiring or sub•contructing .sd�r�atura certifies 4:1n following; "i•C2rtily that in the per3or nanCe of the work for which Sills permit IS Issued,i Shah <br /> employ persons subject to workman's crwpensatioh laws of Caliiornia:' <br />! I hereby certify that !'have prepared this application and that the work will be done in accordance with San Joaquin County .� <br /> ordinances, state laws, and rul and regulatSions of the Joaquin Local Health District. <br /> -APPLICA'NT'S SIGNATURE X _ <br /> _ - FOR DEPARTME&IdONLY <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT'_ ❑ PER SITE _❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jurye31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> FEE f6 <br /> LESS <br /> PRORATION- <br /> PLUS <br /> RORATION_PL s <br /> PENALTY' - _- - R -•'8c ..,p..h.-+ -"°'3 - � , <br /> OTHER - <br /> t <br /> s -OTHER <br /> -93 <br /> Received by Date Receipt No. I Permit No Issuance Date_ ' Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEs4W117/SnERVICES' 166i-E.HAZELTON AVE.,P.O.Boi 2009 STOCKTON,CA 95201" <br />
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