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 /> ENVIRONMENTAL HEALTH PERMIT 81 PTAGE <br /> LIQUID WASTE <br /> f r Applicati s eby car b i ss In the-jurisdictional area of the Joa n Locate ealt istrict <br /> Busines e„(DBA). / Addres <br /> z Owner CK A d ess r� <br /> a � ,, .. <br /> J Firm Partners, Addresses a0d//Telephone Numbers F <br /> aBusiness Telephone No. �7f0�'3533. Emergency Telephone No. � t" 1 <br /> Contractor Licence No. O 57.7. <br /> �Applicants Name (Print) V I C�11__i Title X -- 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 <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 <br /> No. of Vehicles Stored <br /> No_ of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> t R.S. or R.C.E. Name R.S. al;R.C.E. No. <br /> Test Location € Test Date/Time <br /> i 4. S"SANITATION PER11i�1T/ �� I <br /> Job Address/Locatio <br /> I Owner C&Irl 1k4-3'0'_ <br /> j Address <br /> ❑ 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 /> r' Type Construction 71 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I � <br /> 6. ❑ PACKAGE TREATMENT PLANT .For July 1, -June 30, 19 <br /> Operator Name Where Certified ,. <br /> Plant Location <br /> Plant Capacity 4 No. Units Served <br /> 7. ElLAUNDRY For July 1, -June 30, 19 <br /> SIZE: El Less Than 1,000 Sq. Ft., ❑1 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pre this applicagonand that the work will be done in ace dnce with San Joaquin County <br /> ordinances, state laws, and rwt%Afid re ulatio of en Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> YA <br /> FOR DEPARTMENT USE OLY <br /> _Fee Is Due: 13 ANNUALLY _ C1 PER UNIT El PER SITE 1:1 EACH 11J guar a Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASF EXPLANATI N BILLING REMIT? NrCy $ AMOUNT DUE CHECKED <br /> DATE DA REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER 1 <br /> I <br /> i' OTHER A1149 -1 <br /> I r L <br /> �. <br /> Received by Date I Receipt No. IrAyance Lite Mailedelivered <br /> APPLICANT-RETURN ALL COPIES TO: >ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKY ,CA 95201 f. <br />