Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />_ (For Non-Transierable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br />Business Name (pBA),_f�1C�Q <br />U; <br />Address -U_ c� <br />eOwner- _ <br />— —_ Address <br />_ <br />J Firm Partners, Addresses and Telephone Numbers <br />— <br />Business Telephone No.Emergency Telephone No. <br />Contractor Licence No. <br />- <br />Applicants Name (Print)-T�.�1�,_TitlegTt ?1 'Gem Date �_.� e) <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 />C_ <br />Capacity Gal., Weights & Measures <br />Equipment Parking Address. <br />—� <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 />— <br />R.S, or R.C.E. Name _. R.S. or R.C.E. No. <br />Test Location_Test Date/Time <br />4. EirANITATION PERMIT - <br />�At <br />Job Address/Location 14 AA--,OIL%j-F L so - <br />Owner ' e�. tJZ C.� y Address es <br />❑ SEPTIC TANK ❑ CESSPOOL ffrLEACHING FIELD 2 -SEEPAGE PIT ❑ PACKAGE PLANT <br />PERMANENT ❑ TEMPORARY ❑ NEW 9-AEPAIR ❑ 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 />— <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />- <br />— _ <br />Operator Name — <br />- — Where Certified <br />Plant Location <br />— <br />Plant Capacity No. Units Served <br />7. ❑ LAUNDRY <br />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 />l <br />I hereby certify that I have prepared this applicat on and that the work will be done in accordance,, th.Nan Joaquin County <br />ordinances, state laws, nd rules and gulations the San oaq n Local Health District. F <br />APPLICANT'S SIGNATURE X <br />w <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ :Januar 1 & Re <br />RILL N—� <br />By January 31 <br />— BASE— EXPLANATION I G REMITTANCE S <br />_ C / DATEpA� —j REMITTED <br />FEE <br />LESS <br />PRORATION <br />PLUS — — <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date <br />Receipt No. J Permit No. Issuance -Da <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />}601 E. HAZELTON <br />❑ Jufy 1 & Received By July 3T <br />REMIT <br />AMOUNT DUE CHECKED <br />AMOUNT — <br />tg61W <br />Boa 20o9 STOCKTON, CA 95201 <br />