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 /> - t - ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on busin ss in the jurisdictional area of the7a Joaquin LocalHHealth District <br /> yBusiness Name (DBA) & Address— � <br /> z Owner '-' �17 Address i <br /> a <br /> Firm Partners, Addresses and Telephone bars <br /> IL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) r M1~ Title Date�O x <br /> Please check Applicable Category(1-7) and Fill in tRequired 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 /> Capacity 'Gal., Weights S Measures No. <br /> 4 <br /> Equipment Parking Address <br /> 2. 11 PUMPER YARD r _, <br /> For Jury 1� `� June 3:0; 19 <br /> No. of Vehicles'Stored <br /> hd <br /> No. of ChemicalyToilets Stored s<. 1 <br /> 3. 11 PERCOLATION TEST ` <br /> R.S. or R.C.E.-Name ,f R.S. or R.C.E. No. •i 4 .•s <br /> Test-Location "' • Test Date/Time <br /> 4. ❑ SANITATION PERMIT, <br /> Job Address/Location t �� GN 44 A <br /> Own I C! Address '� 7 <br /> SEPTIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT Y. <br /> ❑ PERMANENT ❑ TEMPO RARY,4, ❑ NEW ❑ REPAIR ❑ OTHER, �- <br /> 5. ❑ CHEMICAL"TOILETS For July,1, -June 30, 19 <br /> Type Consfructlon f t Disposal Site �^` <br /> No. of Units ` Equipment Storage/Cleaning Locatiori IV[ <br /> 6. ❑ PACKAGE TREATMENT PLANT eFor July 1, -June 30, 19 <br /> =_ Where Certified <br /> Operator Name t' u o t <br /> Plant Location i• ' ) <br /> Plant Capacity No. Units Served'—. 1 •a� { <br /> 7. ❑ LAUNDRY For July 1, -June 30;.19 <br /> SIZE: ❑ Less Than 1,000 Sq.iFt., ❑ More Than,1„000 Sq.,Ft.e.:-_.—, .,-. •„j - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. �. <br /> "' � rr i� � � A • M <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 r ula ' ns oft n Joaquin Local Health District. "`�'`x' " d <br /> APPLICANT'S SIGNATUREX�* <br /> i F. <br /> 06 <br /> Aj FOR DEPARTMENT•USE ONLY f <br /> r <br /> Fee Is Due: 13ANNUACLY ❑ PER UNIT El PER SITE El EACH ❑ January 1&Received By January 31 `•❑ July 1&Received By July 31 1 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION - AMOUNT DUE _ . CHECKED I <br /> DATE _ DATE REMVT7ED AMOUNT <br /> FEE �~ <br /> LESS z1L� o• I S C ktL i t o f <br /> PRORATION j h -Z1rrt <br /> PLUS rI u,l� l.._•W.rIt, c o.w/?�-4c d.':e7 i 3{rr', - c�ri it•� <br /> PENALTY L .I-. <br /> OTHER <br /> I <br /> ` 4,, Yrxkc Fr a/ r J/ert <br /> f <br /> Received by 7 Date - Receipt No. � Permit No.- � E uan at Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: -ENVIRONMENTAL-HEALTH PERMIT/SERVICES - 1601 E.HAZELT AYE.,P.O.Box 2009 STOCKTON,CA 95201 - <br /> t <br /> _ <br />