Laserfiche WebLink
Applications-WiII.Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION I <br /> { (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT S�PTAG� <br /> LIQUID WASTE x <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 0. <br /> ,r-Business Name (DBA) rL Address ovVWOQ� <br /> z Owner Address <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. ;} <br /> -J Contractor Licence No. t <br /> LApplicants,Name (Print) Title � Date ! <br /> 1 <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> li 1. ❑,PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc:ise Renewal No. v <br /> ii Capacity Gal., Weights & Measures No. <br /> 4 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 /> 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 /> Job Address/Location 177 <br /> E Owner— ,�T/1 7/� Address'5;4�Ax'r <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD:. X SEEPAGE PIT ❑ PACKAGE PLANT 6 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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 <br /> Operator Name ' Where Certified <br /> Plant Location <br /> Plant Capacity 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/Mo. <br /> P <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, ang rules a�ndaulaonsof the San Joaquin Local Health District. j <br /> I APPLICANT'S SIGNATURE X oT - <br /> FOR DEPARTMENT USE ONLY F <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1,&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> . AMOUNT <br /> FEE 6E <br /> LESS '. <br /> PRORATION- <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No.: - Permit No. ssua ce Date Mailedred _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH,PERMIT/SERVICES 1601 E.HAZELTON,AVE.,P.O.BD:.2009 STOCKTON,CA 95201 - <br />