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80-43
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4200/4300 - Liquid Waste/Water Well Permits
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80-43
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Entry Properties
Last modified
7/4/2019 10:42:02 PM
Creation date
12/1/2017 2:09:03 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
80-43
STREET_NUMBER
1
Direction
E
STREET_NAME
WOODBRIDGE
STREET_TYPE
RD
City
LODI
SITE_LOCATION
1 E WOODBRIDGE RD
RECEIVED_DATE
1/29/1980
P_LOCATION
D T MCCLAINE
Supplemental fields
FilePath
\MIGRATIONS\W\WOODBRIDGE\1\80-43.PDF
QuestysFileName
80-43
QuestysRecordID
1991940
QuestysRecordType
12
Tags
EHD - Public
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L. Applications Will Be Processed When Submitted ProperlyCompleted be sure Ioargn 11c„�,r .�.,.,• <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQU.10 WASTE � <br /> Application i ere4Y madq to carry on business in the' risdictionai area of the qan Joaquin al Health D tris! <br /> r <br /> FBusiness Name BA) �6 Address Q' <br /> z Owner <br /> Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> Ii36 S� d S Emergency Telephone No. <br /> m Business Telephone No. <br /> Contractor Licence No. -le) <br /> Applicants Name (Print) Title Dale <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 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 /> 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 <br /> R.S. or R.C.E."No. <br /> R.S. or R.C.E. Name t1� <br /> Test,Lcation Test Date/Time :■l <br /> 4. 6 SANITATION PERMIT �� C <br /> I . G. <br /> Job Address/Location <br /> Owner a AddressS / <br /> 11 SEPTIC TANK 13CESSPOOL M EACHING FIELD ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER \ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site y <br /> No. of Units Equipment Storage/Cleaning Location{s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19_ , <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No.tUnits Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., `0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules nd regulations o th San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedBy July 31 <br /> REMIBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No f Issuance ate Mail 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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