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) <br /> ->�� ENVIRONMENTAL HEALTH PERMIT SEPTAGE j <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) �n7 �i�iYT 01yy SV�!/ Address Win' `FO ,da O��S 7v <br /> z Owner �F� �7n1�� �Jy ___ Address —5AAfE <br /> J Firm Partners, Addresses and Telephone Numbers <br />� 4 Business Telephone No. 3r f'; Emergency Telephone No. <br /> Contractor Licence No. <br /> I! L Applicants Name (Print) . � TitleGero pate <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 /> I 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 <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 'Fd2 / lc:�l AA Address /6 a L nN g <br /> W SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR I$'OTHER �:'4T�r ��� •�i <br /> S. ❑ 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 0 <br /> Operator Name Where Certified .� I <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 /> 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 r s annddf la ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> c <br /> I <br />_ 1 <br /> FOR DEPARTMENT USE ONLY p� <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> 4 ti� DATE DATE REMITTED AMOUNT <br /> k FEE (�.° s f <br /> i "Tj' <br /> LESS <br /> PRORATION 4 .- -- <br /> PLUS <br /> PENALTY <br /> OTHER r ` <br /> OTHER <br /> / - C <br /> I Received by Date Receipt No. Permit No, Issuance Date Mailed re <br /> - APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES ,1601 E.HAZELTON AYE.;P.Q.Box 2009 STOCKTON,CA 95201 !) <br /> �_ <br />