Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 4.9 <br /> L° <br /> • (For Non-Transferable,Revocable, and Suspendable) EPTAGE ' L <br /> a ENVIRONMENTAL HEALTH PERMIT 7y(/ "> <br /> LIQUID WASTE �� <br /> Ap iicatio� ie mcarr a e o co,n�lsine in the jurisdictional area of the 5a a�luin I Health is ict f <br /> F Business Nam A) Address !f <br /> aOwner, Address. .: <br /> J Firm etn rs, Addresses and TeLephogg Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> -4 ContraEtor Licence No. . - <br /> L Applicants Name (Print) Title Date <br /> le <br /> Please check Applicable Category(1-7)and Fill n the Required Information V. r <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 /> Capacity Gal:, Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD _.. <br /> For July 1, June 30, 19 q <br /> e <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 /> 3 Job Address/ ocation 7 s j .T001 <br /> Owner 06,0 442 f ":Address <br /> 01.�SPPTIC TANK CESSPOOLLEHING FIELD G <br /> LIYE PIT PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY &-f!EW REPAIR ❑ OTy�HER r <br /> 5. ❑ CHEMICAL TOILETS For July 1,'-June 30, 19 /✓�'W "� " V /_ <br /> Type <br /> Type Construction -Disposal Site_-_ <br /> No. of Units Equipment Storage/Cleaning Locations <br /> 6. '❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity I 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/Il <br /> ktorrsowner orlicensedogent's_,igP:attjr; ee if^a:hefoltoivirp::'ICIrTtr hat in Thercrlorm4rlteaftbiaworktgrivt?ich-thispermitisissued,Ishallnotemployanypersr <br /> "ir,such ma;36er as to became suhject'o u•otkmar='."•ccn�rs,ls tti:;:;is^w of I;a ifr>,t; f <br /> C©nErastar's h ring <br /> or Sub-ColTiw.tili4J r0gnetasc!.ceKi;ie .tine frail vin t:-�i�t F'#ify 111 at k?-ttic-#'i r Prlii3:sG£of the war%for which th"s p c�'?!.1 i5 iS5,S9L,I S1,-11 <br /> 2myivy p6rsons subject to workman's compensafibn laves of Calltornla." - F <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Co <br /> ordinances, state laws,and rules and recLw4atmions of the an Joaquin Local Health District. 4 G'f ` (�✓`7/ <br /> 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION - AMOUNT DUE (CHECKED <br /> DATE DATE REMITTED - - AMOUNT' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by - DateReceipt No. Permit No. Iss ance❑ to Mailed Delivered. IF <br /> APPLICANT—RETURN ALL COPIES TO: FENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />