Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ` <br /> ,�..�.. y (For Non-Transferable, Revocable, and Suspendable) $EpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 's here made on busi in e' isdictional area of the Sar�, pui cal Hg�I�Distric <br /> NBusiness a �A) �`� Address �[J y y s - <br /> aOwner —Z Addres <br /> Firm Partners, Addresses and Telephone Numbers 7y <br /> aBusiness Telephone Nq. �&�'.5S$3 Emergency Telephone No. <br /> Contractor Licence No. o1:772 C> <br /> Applicants Name (Print) aG� +S'11ELt Title �W' ` 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 /> 1 <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 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT ` <br /> Job Addren fes " <br /> Owner s catioAddress <br /> GYSEPTIC TANK ❑ CESSPOOL grLEACHING FIELD 0,SEEPAGE PIT ❑ PACKAGE PLANT <br /> M-PERMANENT ❑ TEMPORARY ❑ NEW lid-REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br />'f Type Construction Dis P <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 <br /> t 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 /> 1 I <br /> I hereby certify that l have pr re this applic n and that the work will be done h a dance with San Joaquin County <br /> ordinances, state laws, an ule d regulabo of e n Joaquin Local Health Dist k . <br /> ... <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT U E <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH an ry 1 &Received By January 31 ❑July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REM1�IF(T NCE $ AMOUNT DUE CHECKED <br /> DATE E REMITTED AMOUNT <br /> /y/ <br /> FEE 414 <br /> O '0y 0 M1 <br /> LESS <br /> PRORATION' <br /> I L <br />� PLUS <br /> PENALTY s ' <br /> OTHER <br /> j OTHER r � 4 <br /> t Received by Date Receipt No Permit No. - Issu nce Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601LE.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> i <br />