Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> f (For Non-Transferable, Revocable, and Suspendabie) <br /> I ENVIRONMENTAL HEALTH PERMIT­_ SEPTAGE <br /> LIQUID WASTE <br /> Y Appl icatio ereby ade to carp on bysiness in the risdictional area of the S gquin cal Health Distri <br /> w Business Name (DBA) _ �i2�a 1 `� S RAC tj6L e� Address � o ��I T'0 AVC <br /> 1 z Owner / h1 CA 9-G dr- Address <br /> � J Firm Partners, Addresses and Telephone Numbers <br /> 823 668 <br /> f �.S <br /> a Business Telephone No. Emergency Telephone No. R <br /> Contractor Licence No. 3 <br /> ` L Applicants Name (Print) Title Date ti <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. Licc.se 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 Addressocation IS'3el.S Co-77 A6 AV G /Pl m7eca3 <br /> Owner— 4-YAI /;/L,0eR.S0,0V Address <br /> OO'SEPTIC TANK ❑ CESSPOOL ®'LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ 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) Lam <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 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 and regulations of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 2 <br /> FOR DEPARTMENT USE ONLY <br /> �p Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT f e� <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> IT <br /> DATE DATE REMITTED. AMOUNT <br /> s <br /> l' FEE <br /> LESS <br /> PRORATION s' <br /> PLUS <br /> PENALTY <br /> ' OTHER l <br /> K OTHER s <br /> j Received by Datd Receipt No. Permit No. Issuance Date Mailed Delivered <br /> lil APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SERVICES .1601 E,HAZELTON AVE.,P.O:Bos 2009 STOCKTON,CA 95201 <br />