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82-107
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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82-107
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Last modified
7/25/2019 10:08:56 PM
Creation date
12/3/2017 1:48:43 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
82-107
STREET_NUMBER
2446
STREET_NAME
MCCOMB
SITE_LOCATION
2446 MCCOMB
RECEIVED_DATE
3/16/82
P_LOCATION
DAVE DUKHORT
Supplemental fields
FilePath
\MIGRATIONS\M\MCCOMB\2446\82-107.PDF
QuestysRecordID
1847919
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) r SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT l <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) Ec TM-ral c Septic _& Ra ckhae, - Address <br /> a Owner— T R. P�cDo1a1 t) Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. x31_049 7 _ Emergency Telephone No. <br /> Contractor Licence No. 733679 <br /> L Applicants Name(Print) Title Date <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 /> Description(Make/Yr., Color) <br /> Serial No. _ CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address 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 Address/Location <br /> Owner — Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑_NEW REPAIR ❑ OTHER 6- <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 /> r <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 /> 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 a San Joaquin Local Health District,=-------__ <br /> APPLICANT'S SIGNATURE <br /> IF <br /> FOR DEPARTMENT USE Y <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> OQ <br /> FEE .} <br /> LESS <br /> PRORATION <br /> PLU: JY <br /> PENALTY <br /> OTHERUv- <br /> / <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />
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