My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
SU0000268
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
M
>
MOHLER
>
24369
>
2600 - Land Use Program
>
MS-89-20
>
SU0000268
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
2/20/2020 10:20:19 AM
Creation date
2/20/2020 9:19:31 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0000268
PE
2622
FACILITY_NAME
MS-89-20
STREET_NUMBER
24369
Direction
S
STREET_NAME
MOHLER
STREET_TYPE
RD
ENTERED_DATE
9/18/2001 12:00:00 AM
SITE_LOCATION
24369 S MOHLER RD
QC Status
Approved
Scanner
SJGOV\gmartinez
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
20
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �? APPLICATION <br /> A � t (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> 0ENVIRONMENTAL 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 <br /> rn Business Name (DBA) Address <br /> zOwnerSAE' At�'Q ROMA t4SU '/'F—Ir► Address 24Z(,-9 Ste• MnHL.r—_J`LL TGIF<01-4 C¢... !)51_3616. <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBt+sk%bss Telephone No.(G 9) 599 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title �-0, tL C SMUfa! Date 1Z' <br /> Please check Applicable Category (1-7)and Fill in the Required Information 418 Mf%-rT+AE-W 1>LA-7-A <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) LO5J1 j cN` 9SZA-00 <br /> For July 1, June 30, 19 Disposal Sites t� 3 4-1 S!9 <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. X PERCOLATION TEST �t <br /> R! R.C.E. Name �-'C CU IS R-6-er R.C.E. No. <br /> Test Location L a VICI -Test Date/Time t� 1�A�l\� �V1t l� l'2 ` l4- 88 Wry—PAM <br /> 4. ❑ SANITATION PERMIT(SEE Pi-o-T,PLikIA L�1=�1-4 � <br /> AC_ ) <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or licensed aqent's signature certifism the following:'1 cPrtify that in the performance of the work for which this permit is issued,I shall notemploy any person <br /> in such manner as to become subject to workman's.1ompensati^r latys.f R�Gfon;rJ" <br /> Contractor's hiring or sub-contrarting signature certifies the r <br /> 311ov n,: 'I certify that in the performance ill the work for which this permit is issued,I shall <br /> employ persons subject to workma s cumpensation laws of Catiforuia:' <br /> I 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 and regulations of the Soman..Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 1/❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> III BILLING MITTANCE $ REMIT <br /> BASE EXPLANATION DATE I DATE AMOUNT DUE CHECKED <br /> REMITTED <br /> AMOUNT <br /> FEEQf✓ / <br /> . ,LESS 4..... <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ANN <br /> OTHER <br /> ��'/`T <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed elivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />
The URL can be used to link to this page
Your browser does not support the video tag.