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81-631
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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81-631
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Entry Properties
Last modified
7/18/2019 3:01:09 AM
Creation date
12/4/2017 9:44:50 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
81-631
STREET_NUMBER
14467
Direction
N
STREET_NAME
DE VRIES
STREET_TYPE
RD
City
LODI
SITE_LOCATION
14467 N DE VRIES RD
RECEIVED_DATE
09/23/1981
P_LOCATION
HART BROS
Supplemental fields
FilePath
\MIGRATIONS\D\DE VRIES\14467\81-631.PDF
QuestysFileName
81-631
QuestysRecordID
1713562
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) <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE <br /> Application is hereby madeto ciT on business in the jurisdictional area of the San Joaquin Local Health <br /> "7District <br /> Business Name (DBA)--H Q [1 �� Address 3�/� W I�.yr��,(�� f <br /> aOwner� (7 Address 3c� -5 ��7 �l'�A - <br /> Firm Partners, Addresses and Telepho a Numbers C <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No- <br /> Applicants Name (Print) :P o A"I A H NP � Title Date O �- 3 - 151 <br /> Please check Applicable Category(1-7) and Fill in the Required Information z <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites . <br /> Description(Make/Yr., Color) I <br /> Serial No. E CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> j For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. .. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> F <br /> Job AddresAddress/Location "' s 1 <br /> Owner NAR-7- .._..1 R a S Address C <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ 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 Certified -1`•_ <br /> Plant Location =— <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, aannd rule_ s and regulations of the San Joaquin Local 4alth District. <br /> APPLICANT'S SIGNATUREX /�`� •�f� �1/�'�SyILI �jl�--� <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: I] ANNUALLY ❑ PER UNIT ❑ PER SITE_ ❑ EACH - -❑ January 1 &Received By January 31 ❑ July 1 &Received BY July 31 <br /> REMIT <br /> BILLING REMITTANCE $. <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOU � <br /> D / <br /> FEE � �^� � " � <br /> LESS ` <br /> PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> v r � <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Delivered — � <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />
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