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79-833
EnvironmentalHealth
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JAHANT
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4200/4300 - Liquid Waste/Water Well Permits
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79-833
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Entry Properties
Last modified
6/28/2019 10:51:55 PM
Creation date
12/2/2017 6:11:43 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
79-833
STREET_NUMBER
1266
Direction
W
STREET_NAME
JAHANT
STREET_TYPE
RD
City
ACAMPO
SITE_LOCATION
1266 W JAHANT RD
RECEIVED_DATE
9/20/1979
P_LOCATION
RANDY LANGE
Supplemental fields
FilePath
\MIGRATIONS\J\JAHANT\1266\79-833.PDF
QuestysFileName
79-833
QuestysRecordID
1799285
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 SuspendabEe) rTE ENVIRONMENTAL HEALTH PERMIT 4.1;LAI <br /> LIQUID WASTE <br /> Application i reby made to c ry on busin s in th jur di ional area of the S oa In Local Health Di ict <br /> HBusiness Name (D } - j Address 0 7 <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbe <br /> CL a Business Telephone No. � Emergency Telephone No. <br /> Contractor Licence No. :)-4T Z _ <br /> L Applicants Name(Print) dD Title e .t cq Date <br /> 9-13_-7 <br /> Please check Applicable Category (1-7)and Fill in the Required Information -Xj <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,1 + R_ _June 30, 19 Disposal Sites C1 <br /> Description(Make/Yr., Oolor) <br /> Serial No, CAL. License No. CAI_. License Renewal No. <br /> i <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑—PUMPER YARD <br /> For July,1_, .1june 30, 19 L <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> j <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Lration Test Date/Time ' <br /> 4. I� SANITATION PERMIT <br /> Job Address/LocaAon <br /> Owner Address G <br /> PPERMANENT <br /> EPTEC TANK ❑ ESSPOOL ,�, IEACHING FIELD SEEPAGE PIT ACKAGE PLANT {❑ TEMPORARY I-Ia'NEW ❑ REPAIR ❑ OTHER f <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I <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 4" <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 /> 1 <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 rul nd regula7s of t an oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 'FOR DEPARTMENT USE ONLY <br /> •41t I <br /> Fee Is Due: 13 ANNUALLY El PER UNIT- PER SITE ❑ EACH .❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BILLINGi REMITTANCE $1 AMOUNT DUE CHECKED <br /> DATE v7 DA,TTyE� REMITTED AMOUNT <br /> FEE ,�/ S> <br /> LESS Sy <br /> i <br /> PRORATION ++ter <br /> PLUS <br /> PENALTY <br /> OTHER 4 <br /> OTHER <br /> 7S- <br /> Received by Date Receipt No. Permit No, Issuan Date Mailed elivere p� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2999 STOC N,CA 95201 O <br /> ' 9�z/7 <br />
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