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) ca <br /> * ENVIRONMENTAL HEALTH PERMIT SE P1 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA Address d <br /> aOwner a r Address ?�/ �� .Ff-6-V C4 a 14ac �" <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. L/C2 - G J Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print, ✓ on Title 4!Jim e0'r' Date <br /> Please check Applicable Category ( -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 Location Test Date/Time <br /> 4. n SANITATION PERMIT / w <br /> Job Address/Locatio 0 r' OG �O�n <br /> OwnerAddress ' e r' <br /> SEPTIC TANK llC SSPOOL M LEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 0 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, a rules and regulations the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: C3 ANNUALLY ❑ PER UNIT PER SITE 11 EACH ❑ January 1 &Received By January YJ�Rece' d July 1 <br /> BILLING REMITTANCE $ R IT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE HECKED <br /> AMOUNT <br /> FEE �� j !/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY y <br /> OTHER <br /> OTHER <br /> LQ. 1,4 <br /> ,;,jq ?? Fo aU 75S <br /> Received by Date Receipt No. Permit No. Issuan a Date Mailede i ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Box 2009 -__ TON, A 95 1,y <br />