Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> P_ (For Non-Transferable,Revocable,and Suspendable) Sr PT AC E <br /> f� '• ENVIRONMENTAL HEALTH PERMIT <br /> /� LIQUID WASTE <br /> Application oirVfnade t arry,gl�bu�sjness in the jurisdictional area of the`�®juin Locaealth Dist`i <br /> J E ddress �. ' (� <br /> NBusiness jm�i(DBA)/,/� Address <br /> aOwner_—�f�/ !/�� <br /> Firm Partners, Addresses and Telephone Numbers <br /> G G Emergency Telephone No. <br /> 0. ,X Telephone No. 1 �-- <br /> Contractor Licence No. f Title Date <br /> LApplicants Name (Print) V� <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACCH al H VEHICLE) <br /> For July 1, June 30, 19 <br /> es <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Gal.,Weights&Measures No. <br /> Capacity <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 R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location v <br /> 4. SANITATION PERM Ad <br /> Job Address/Location�/!• Address <br /> OtEPTIC <br /> ner �''� ❑ PACKAGE PLANT <br /> TANK ❑ CESSPOOL v LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> ERMANENT <br /> ❑ TEMPORARY -NEW 11 REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 1Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <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 /> Ed this appl' tion a d that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have pr of th <br /> ordinances, state laws, and les d gu Ion San J uin Local Health Dct. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> REMIT <br /> $ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 3 <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE SVJ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. <br /> ss ce <br /> rmit No. � �s nate ailed Delivered ` a <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E. ceON AV Box 2009 STOC <br /> APPLICANT—RETURN ALL COPIES TO: KTON,CA 95201 <br />