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82-234
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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82-234
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Entry Properties
Last modified
7/27/2019 10:08:07 PM
Creation date
12/5/2017 1:36:24 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
82-234
STREET_NUMBER
2304
STREET_NAME
ESTATE
STREET_TYPE
DR
City
STOCKTON
SITE_LOCATION
2304 ESTATE DR
RECEIVED_DATE
05/25/1982
P_LOCATION
MR HOLLAWAY
Supplemental fields
FilePath
\MIGRATIONS\E\ESTATE\2304\82-234.PDF
QuestysFileName
82-234
QuestysRecordID
1733188
QuestysRecordType
12
Tags
EHD - Public
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Applications Will Be Processed When Submitted Properly Completed. Ise sure iu o+ai+ +,+�^rr jr t <br /> - IAPPLICATION „ <br /> ;For Nort-Transferable,Revocable,and Suspendable) SEPTAQE, ` <br /> ( . <br /> JN <br /> '- Xti;y.rt -�¢},� ENVIRONMENTAL HEALTH PERMIT 1 + <br /> (LIQUID WASTE <br /> Applic 'on i her de to`c�r on usiness in the jurisdictional area of the San oaquln Local Health Dista tf <br /> r sa>•'f- �✓'�S <br /> Business Name (DBA) Address <br /> Address <br /> aOwner u - <br /> J Firm Partners, Addresses and Telephone Nu01 mbers Emergency Telephone No _ <br /> IL Business Telephone No. !� <br /> J Contractor Licence No. <br /> TitleDate <br /> , <br /> LApplicants Name (Print) T M Y ^ A <br /> Please check Applicable Category (1-7)and Fill in the Required information tw <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,09 =Disposal Sites - } <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> CAL. License No. <br /> Serial No. <br /> -Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD k; ... .--� ..�. - It <br /> 1 <br /> For July i,,--' ��June-30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored"° <br /> 3. ❑ PERCOLATION TEST' R.S.;or R.C.FINo. s <br /> R.S. or R.C.E.Name <br /> Test Date/Time.'— <br /> Test ocation <br /> t 4. SANITATION PERMIT, ` a r- � "� d.#.-7 k, <br /> Job Address/Lodation �S`L`�'� '. �� ' <br /> e~ <br /> l nor �`� °" Address <br /> C3EACHING FIELD EEPAGE PIT PACKAGE PLANT <br /> O �s <br /> EPT.IE'rTANK :i,❑"fESSPOOL REPAIR [I OTHER <br /> -s* Rte❑ TEMPORARY , Tj <br /> �PERMA?VENT �..,_.f f <br /> 5. ❑ CHEMICAL T61L•ETSj For July 1,-June 30, 19 = <br /> a <br /> Disposal Site t,.•,•. <br /> 1. Type Construction ,.. <br /> + I Equipment Storage/Cleaning Location(s) { f. <br /> +" No. of Units 1 <br /> r.. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified - <br /> t <br /> Operator-Name <br /> Plant Location <br /> No. Units Served s: <br /> Plant Capacity } <br /> 7. ❑ LAUNDRY '`For July 1,i-June 3019' <br /> SIZE: ❑ Less Than:1,000 Sq. FL, ❑ More�Than i.1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. ' <br /> g <br /> Nome owner or licensed agent's signature certiffestheiollowing:"feertily thatintheperformattCoottheworkfor whichthisyermitisissued.Isha`inotemployanypersan <br /> Ill such manner as to become subject to worlunari s compensation laws of Ga4ifomia. <br /> Contractor's hiring-'.at stab-cafttaetina slgnatur+ eeroirws th." toNowin9: t certify that in isle pffformance of the work for which this permit is issued,l shall f a <br /> employ-persons subject to workfnans compsnsalleo laws i Cali:Or--fie. # ; ,W �JI-blei; r :s ,�, r h� <br /> ,t :� r <br /> I hereby certify that I ha repared this application and�1aethe work..' <br /> lHealth D strict e inccoidanci3 with'San Joaquin County i <br /> f ordinances, state laws d I and reg ions oft an Jo Lo # <br /> APPLICANT'S SIGNATURE X s� 4 <br /> i. 4, <br /> + I FOR DEPARTMENT.-USE ONLY <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH EI January 1 &Received By January 31 El July 1 &ReceiveREMlTBy uly 31 <br /> BILLING _ REMITTANCE $ AMOUNT DUE CHECKED <br /> ( ° BASE EXPLANATION DATE DATE REMITTED AMOIfNT <br /> ~ FEE -4 <br /> LESS u JS y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER .' <br /> xto <br /> Receipt No. Per a. Issuaric Date Mailed Delivered <br /> Received:by Date _ <br /> a 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL REALTN PERMITlSERVICE5 <br />
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