Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> I (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGEo <br /> j G 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) 12 A elez-SZI _5k_1A1-- Address �� .X /6��0 <br /> a Owner IV9A P,4eveisll Address s_ <br /> Firm Partners, Addresses and Telephone Numbers 4...._ <br /> CL <br /> Business Telephone No. '` � 9�� Emergency Telephone No. V <br /> Contractor Licence No. 5 3 7� <br /> ' S!/�YJA77J <br /> Applicants Name (Print) r� y� Zl e7 0jp! Title Date <br /> Please check Applicable Category(1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 5 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) f; <br /> Serial No. CAL. License No. CAL. Licznse 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 F R.S. or R.C.E. No. <br /> Test Location e ` Test Date/Time <br /> 4. X SANITATION PERMIT <br /> Job Address/LocatiorL _-_ _ _ <br /> Owner �A� .�7A 220 Q u I A.) . Address r S '� S -- 7 <br /> 1:1 SEPTIC TANK t] CESSPOOL x?l LEACHING-FIELD 0 SEEPAGE PIT 0 PACKAGE PLANT- ►'- �r <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW -,- §( .REPAIR OTHER, ' <br /> c. 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' <br /> i Type Construction 'Disposal Site <br /> l No. of Units '' Equipment Storage/Cleaning Locatiorn(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location _ <br /> I Plant Capacity No. Units Served ' <br /> i 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 /> l <br /> r <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 aod_r"egulations e n Jdaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> - - �.A <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Ju4y 31 <br /> REMIT <br /> BASE <br /> ' <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED '{ AMOUNT <br /> FEE <br /> LESS i <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> OTHER <br /> Received by Dat Receipt No Permit No. Issu nce ate Mailed Delivered r <br /> .M1 /,,p` 4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTOR, i5201 <br />