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79-1070
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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79-1070
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Last modified
6/18/2019 10:37:09 PM
Creation date
12/1/2017 5:25:57 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
79-1070
STREET_NUMBER
744
Direction
W
STREET_NAME
PELTIER
STREET_TYPE
RD
City
LODI
SITE_LOCATION
744 W PELTIER RD
RECEIVED_DATE
12/11/1979
P_LOCATION
LEONARD THOMPSON
Supplemental fields
FilePath
\MIGRATIONS\P\PELTIER\744\79-1070.PDF
QuestysFileName
79-1070
QuestysRecordID
1897087
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 /> r (For Non-Transferable, Revocable,and Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 0 <br /> r Application is reb'y made carryon business in the jur dictional area of the San Local Health Dis O <br /> ti Business Name BA) Address td <br /> aOwner .II Address <br /> 0 Firm Partners, Addresses and Telephone N&bers <br /> aBusiness.Telephone No. �� -tr Emergency Telephone No. <br /> Contractor Licence No. 2- <br /> Z �- <br /> L Applican4 Name (Print) < TitleDate le - 11 - 77 <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 /> e - <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. Name R.S. or R.C.E. No. <br /> Test L ation Test Date/Time <br /> 4. Lff SANITATION PERMIT <br /> Job Address/LOc9on . ) <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL EACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 0'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 <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. f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. �. <br /> 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, and rules "regulations of the San Jo quin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT PER SITE ❑ EACH ❑ January 1 &Received <br /> �By,January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE a '�•1 REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER , <br /> i <br /> OTHER <br /> —7 c9 o <br /> Received tzy Date Receipt No. Permit No. Issuance Da! Maileff Deliv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEI.TON AVE.,P.O.Box 2009 STOCKTON, A�01 —_ <br />
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