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82-617
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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82-617
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Entry Properties
Last modified
7/31/2019 10:14:46 PM
Creation date
12/5/2017 11:37:01 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
82-617
PE
4210
STREET_NUMBER
12668
STREET_NAME
BYRON
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
12668 BYRON RD
RECEIVED_DATE
10/20/1982
P_LOCATION
MICHAEL FARLEY
Supplemental fields
FilePath
\MIGRATIONS\B\BYRON\12668\82-617.PDF
QuestysFileName
82-617
QuestysRecordID
1674248
QuestysRecordType
12
Tags
EHD - Public
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t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ® (For Non-Translerable,,Revocablil, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the,jurisdictional area of the San.Joaquin Local Health District, t, <br />` Business Name(DBA) " . <br /> v, .Address <br /> i Owner _ Address <br /> f 2 Firm Partners, Addresses and Te a hone Numbers F <br /> r t.. <br /> I a Business Telephone No. ��� 0 - EmergencyTelephone No. <br /> I 3 �1 <br /> Contractor Licence No. - .5 <br /> Applicants Name (Print) �� G L�trT -.Title d" -Datet_h <br /> Please check Applicable Category(1-7)and Fill'in Ithe Required Intrmation <br /> i 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. F CAL�-License No. i 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. Name R.S. or R.C.E.No. <br /> Test Location'-1.777Test Date/Time <br /> i <br /> 4. M SANITATION PERMIT-----•� �^ - <br /> r f a { <br /> Job Address/Location t�+�$St <br /> .. <br /> Owner f <br /> L Address R�r' r <br /> I El SEPTIC TANK ❑ CESSPOOL :113 LEACHING FIELD _0 'SEEPAGE PIT ❑ PACKAGE PLANT <br /> r 11PERMANENTI ❑ TEMPORARY NEW N 13REPAIR ❑ OTHER <br /> -5. ❑ CHEMICAL TOILETS For July 1,=June 3019. ,E <br /> t. <br /> Type Construction -Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE:TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name t - -- . - Where Certified I t <br /> Plant Location _ <br /> Plant Capacity ) o. Units Served <br /> 7.--❑ LAUNDRY For July 1, -June 30, 19 r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.,Ft. ' <br /> ❑ DRY%M 91lemicils Used/Amount/Mo. <br /> o Icent�e 'erIt'ss;pianitsreC.cr::F:ga1>*�r�Ita�;inn:"Ice-t#fy=,i= s* poiIG1,Manceofthework for which this permit <br /> isissued,lshahnotemployanypersan <br /> In such manner a5 t0 t31?CpfriB$L't1lEf:t tFi N'Gr;:31a(?'j��, R�`,'.ii�7ilr�ii}ii'i'S G? z11SfL'1"i?°;{•'L °' . <br /> Contractor's hiring or suly-cmYra,^.tir `0atur ;#;�; th,, fall-AdaG: "I certify that ill the performance of the work for which this permit issued,I shall <br /> employ persons subject to workman's ccmper;af:ai;lav s hi Cali€ornia."' <br /> r l hereby certify that I have preipared'this'application and that the work will be done in accordance with San Joaquin County <br />�- ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.; r r <br /> APPLICANT'S SIGNATURE X <br /> IrFOR DEPARTMENT USE ONLY...,:_.,-_- �. <br /> t Fee Is Due: ❑-ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1 &Received By-January 31 : ❑ July 1 &Received By July,31 <br /> i - i,- REMIT <br /> BILLING REMITTANCE .$ <br /> i BASE EXPLANATION AMOUNT DUE CHECKED <br /> -- DATE DATE -REMITTED qy rAMOLS'NT <br /> FEE ... . - <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY a <br /> OTHER <br /> I OTHER a <br /> • Received by Date iReceipt No. -Permit No Issuarfoe Date_ - .Mailedf Delivered ' <br /> APPLICANT-RETURN ALL COPIES TO.-" ENVIRONMENTAL HEALTH-PERMIT/SERVICES" 1601 E.HAZELTON AVE.,P.O.Box-2009 STOCKTON,CA95201 <br /> r <br />
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