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80-287
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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2007
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4200/4300 - Liquid Waste/Water Well Permits
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80-287
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Last modified
7/3/2019 10:55:29 PM
Creation date
12/3/2017 6:07:59 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
80-287
STREET_NUMBER
2007
STREET_NAME
NORD
STREET_TYPE
AVE
City
STOCKTON
SITE_LOCATION
2007 - 2017 - 2027 NORD AVE
RECEIVED_DATE
5/9/1980
P_LOCATION
THOMAS R GRAVES
Supplemental fields
FilePath
\MIGRATIONS\N\NORD\2007\80-287.PDF
QuestysRecordID
1871169
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 /> Appllcation is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,„Business Name (DBA) Address� <br /> a Owner Address 77�.� C.A.ei�/✓ ,��. �J�T� j7J�. <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No.� <br /> 1 Contractor Licence No. 1 <br /> L Applicants Name (Print)�Td1i��s` �7.C'A �/��5_ 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 4, 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 <br /> 2. ❑ PUMPER YARD v <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored D <br /> No. of Chemical Toilets Stored V <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. WANITATION PERMIT <br /> Job Address/Location Od7 _ d�7'" Q�' 7 <br /> Owper � AAddress \1 <br /> PTIC TANK 11 CESSPOOL ACHING FIELD C3 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY L�7 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 /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq in County <br /> ordinances, state laws, auies and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> d✓ 0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is flue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 5 &Received B January 31 ❑ July 1 &Received By July 31 �I <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BA5E EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by D to I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009, STCKTT�fy,if�52t11 <br />
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