Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAOE ' <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District i <br /> Business Name (DBA) Address <br /> i Owner Address <br /> z <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 'r+��S' 3 �� Emergency Telephone No. <br /> a , <br /> Contractor Licence No. <br /> L Applicants Name (Print) e9Title OtdA�eAL Date-1-0— 77-70. <br /> Please check Applicable Category (1-7)and Fill in the Required Information Q <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) G <br />` For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewat 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 /> 1. <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location /2-1-1 .5- <br /> Owner 1/l To PA VIA Address <br /> 0 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 9 PERMANENT ❑ TEMPORARY 19 NEW ❑ REPAIR ❑ OTHER V ! <br /> t 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t <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 /> t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <br /> ir l hereby Certify that I,have prepared this application and that the work will be done in accordance with San Joaquin County ,P <br /> ordinances, state laws, and-rules and regulati of the San Joaquin Local Health District. <br /> I _ <br /> t. APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION - BILLING REMITTANCE $ AMOUNT DUE CHECKED- : <br /> DATE DATE REMITTED AMOUNT <br /> FEE y�� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �z <br /> OTHER' <br /> OTHER <br /> -$'O <br /> l <br /> F Received by Date - Receipt No. Permit No. Issuance Date a' Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.;-P. x 2009 STOCKTON.CA 952 <br />