Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 40~ =�' �l (For Non-Transferable, Revocable, and Suspendable) <br /> �y ENVIRONMENTAL HEALTH PERMIT SFPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District _ <br /> H Business Name (DBA) ',Z AddressC-�, � � <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> m Business Telephone No. 44��'62 Emergency Telephone No. <br /> Contractor Licence No. i L '�_ <br /> L Applicants Name (Print) L T i t I e I&AATC3 Z 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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Loca ion Test Date/Time <br /> 4. 31SANITATION PERMIT <br /> Job Address/Location 6C L S- fel F:Ie_'� i <br /> Owner Address YA <br /> B'SEPTIC TANK ❑ CESSPOOL BILEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT C7 <br /> C'PERMANENT ❑ TEMPORARY CINEW ❑ 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 /> I hereby certify that I have prepared this application an that the k will be done in accordance with San Joaquin County <br /> ordinances, state laws, a les and reg Ions of th S n Jo n ocal Health District. <br /> APPLICANT'S SIGNATURE X 1 „tel <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE L[ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issuan a Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />