Laserfiche WebLink
-21 Ap s Will Be Processed When Submitted Properly Gompieteu. <br /> APPLICATION <br /> (For Non-Transferable; Suspendabie) $EPTAGE <br /> ,- <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIWASTE , <br /> Application is hereby made to carry bjjsiness in a juriQUi0 sdictional area of.trie San Joaquin to a1 H It District y <br /> Address <br /> rn Business Name (DBA) Address <br /> _4 Owner � <br /> Firm Partners, Addresses a SRI hone Numbers Emergency Telephone No - <br /> aBusiness Telephone No. tf _ <br /> Contractor Licence No. _ Title Date <br /> LAPPlicants Name (Print)= .�► "1 r <br /> Please check Applicable Category.(1-7) and Fill in the Required Information <br /> 1, <br /> 13 PUMPER VEHICLE-PERMIT'REGISTRATION {FOR EACH VEHICLE) <br /> For July 1, <br /> June 30, 19 - = Disposal Sites - <br /> Description(Make/Yr.,Color) CAL. License No, CAL. License Renewal No. <br /> Serial No. <br /> -G al-Weig hts-8r Measures-No: <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD �..r --_---- - a,-- <br /> June 3RD 19�"- <br /> I '`For,duly 1;__— [ <br /> No.of Vehicles Stored t <br /> No. of Chemical Toilets Stored ' <br /> 3. 0 PERCOLATION TEST -` R.S.or No. <br /> R-S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. 0 SANITATION PERMIT, f 0 t <br /> LIJ L1 <br /> r s/Location <br /> Job Add <br /> t �.' Addre s ` <br /> O <br /> pr ❑ PACKAGE PLANT <br /> ❑ CESSPOOL'S EACHaNG FIELD SEEPAGE PIT <br /> SEPTIC TANK e I ❑ OTHER F <br /> ❑ TEMPORARY- NEW REPAIR 4 f r <br /> PERMANENT I E 1 <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 1919 <br /> Disposal Site t <br /> Type Construction < <br /> 1 . Equipment Storage/Cleaning Location(s) <br /> No. of Units i <br /> 6• 0 PACKAGE TREATMENT PLANT For July i, -June 30, 19 y Where Certified <br /> Operator Name - <br /> i Plant Location } <br /> I No. UriitstServed `� <br /> - Plant Capacity <br /> 7. ❑ LAUNDRY For July'1,-June 30, 19 f <br /> ❑ Less Than 1,000 Sq: Ft.,t ❑ More Than 1,000 Sq.'Ft <br /> SIZE: . . <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ".r.reo�vnerorli�onserlan^nt'S ignaturwcerti�t+athPfeltovrina "Icr lanceotthewcr!;#or`�v#iichchispermiti5issued,Ithallnotempioyanypersap- <br /> S rnn9r' -1.0C' .�_ a3 x•riiiSiCh nlinreraStO bCC M .Jct 6: n .,v:.. l`-`., ly ,•� ;El ..,C F• l JL'k!or which ttlp pOTlfl is <br /> SSklfld,I shaft <br /> Contrnctor^ hirino Cr ' <br /> Employ Fcrsons sui,;eci <br /> r 1 <br /> ' application nd that the work will berdone in accordance with San Joaquin County ( <br /> t I hereby certlfp,that 1 have prepared t is app nl Jo' uin Local Health District.. t <br /> ordinances, .tate laws, and ries and r$gy a _ I <br /> ! 1 r <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY- f <br /> C - t ! <br /> jll ❑ January 1 &Received By January 31 July 1 &'Received By July 31 <br /> Fee is Due: ❑ ANNUALLY ❑'PER UNIT <br /> PER SITE ❑ EACH s REMIT \ <br /> REMITTANCE $ OUNT DUE CHECKED <br /> t BILLING +,REMITTED AM- AMOUNT <br /> :BASE EXPLANATION DATE - DATE <br /> . � .. <br /> I <br /> FEE <br /> 33 <br /> E LESS <br /> s PRORATION _ `' - •�t <br /> PLUS ." f <br /> I.. '-PENALTY <br /> OTHER -w t <br /> r t 4/•' ft <br /> OTHER rX�1 <br /> issue ate Mailed Delivere ..�.+ <br /> _ Receipt No, F_Permit Na-. �, „�,,..... - CA 45201" <br /> 'eceived:,y W. e-•- +---�-^� - 1601 E.HAZ AVE.,P.Q.aox 2009 STOCKTON, 3 <br /> �ApPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES-� <br />