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) 'SE.PTACE, <br /> ENVIRONMENTAL HEALTH PERMIT o <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> cn Business Name (DBA)DARA-Q Address Fo rOkC 1ASO,ISTT{tom, SSZO I <br /> aOwner Address <br /> 7u Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. LI Co —x(56= Emergency Telephone No. <br /> Contractor Licence No. a 9 43 -- <br /> Applicants Name (Print) Title M—&OAGE�:Q 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 - k <br /> Description(Make/Yr.,'Color) S <br /> Serial No. CAL. License No. CAL. License Renewal No. °d <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 /> { <br /> 3. ❑ PERCOLATION TEST r - <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time t <br /> 4. V SANITATION PERMIT l' <br /> Job Address/Location <br /> Owner RA'/l!°10N'n 1l4E'NCk4 ' Address t5&1AE - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD -0 SEEPAGE PIT ❑ PACKAGE PLANT t , <br /> R PERMANENT ❑ TEMPORARY ❑ NEW �IA 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) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name Where Certifidd <br /> Plant Location <br /> Plant Capacity `y° No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 1W r r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑•More Than 1,000 Sq. Ft. ` r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. + <br /> 1•Iprnp.owner ortic"sed agents s4"ture "l verlitythat in the performm:e of the work f orwhich this permit Is issued,I shall not employ any{lerson <br /> to such manner as to become subject to workman's ciDmpensation laws of California:' <br /> Contractor's hiring or sub-can trawkg signature eerttFies t%e foflowtng: 1 certify that in the performance 6 the work for which this permit is issued.I shall <br /> employ persons subject to workman's compensation laws of California:' *. <br /> hereby certify that I have epared this a ication and t the work ill be done in accordance with San Joaquin County <br /> ordinances, state laws, a r e and regul i ns of the oaqui oca He th District. <br /> -V77S <br /> APPLICANT'S SIGNATURE X ' <br /> e <br /> F <br /> r` <" FOR DEPARTMENT USE ONLY 11 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 33 e ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITT AMOUNT DUE'" CHECIfED <br /> AMOUNT <br /> �,} O� <br /> 'FEE 1� i r Wit, 3 c <br /> LESS <br /> PRORATION <br /> IPLUS <br /> .PENALTY <br /> OTHER _ _ <br /> .OTHER <br /> Received by Date Receipt No. Permit No. Is a e Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />