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80-559
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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80-559
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Last modified
7/7/2019 10:32:51 PM
Creation date
12/1/2017 5:18:55 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
80-559
STREET_NUMBER
1460
Direction
W
STREET_NAME
PELTIER
STREET_TYPE
RD
City
ACAMPO
SITE_LOCATION
1460 W PELTIER RD
RECEIVED_DATE
8/18/41980
P_LOCATION
DELTA DEVELOPMENT CO
Supplemental fields
FilePath
\MIGRATIONS\P\PELTIER\1460\80-559.PDF
QuestysFileName
80-559
QuestysRecordID
1896874
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 SEPTAGE <br /> LIQUID WASTE <br /> Application ' he eby rn car n busi s in the jurisdictional area of the San Joaquin all It i i <br /> NBusiness ame DBA) Addre d <br /> aOwner Address <br /> Firm Partners, Addresses and Tel one NU.Enbers <br /> aBusiness Telephone No. 5~ Emergency Telephone No. <br /> Contractbr Licence No. 3 6.3 � <br /> Applicants Name (Print) Title Dat <br /> Please check Applicable Category (1-7) and Fill in the Require Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Julyfl, June 30, 19 Disposal Sites <br /> t <br /> Description(Make/Yr., Color) <br /> Serial N6. CAL. License No. CAL. Licc;sse Renewal No. <br /> Capacity' Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> r <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 Test Date/Time <br /> 4. SANITATION PERMIT / <br /> Job Addy /L n �d d <br /> Owner Address <br /> Q <br /> KSEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 1KNEW ❑ REPAIR OTHER 3- . <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 <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, les and re ul ions of th Joaquin Local Health District. ! <br /> ti <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Feb Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT , <br /> .i <br /> FEE s 4 L45 <br /> LESS <br /> PRORATION t <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issuatice Date Mailed Delivered <br /> h <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVP /�Boo(20D9�,tSTOCKTON,CA 95,;01 <br />
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