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) <br /> i . ENVIRONMENTAL HEALTH PERMIT SEPT/�GE <br /> LIQUID WASTE <br /> s <br /> Application is hereby made to carryon businesp in the jurisdictional area of the San <br /> Joaquin Local Health istrict <br /> Business Name (DBA) ' al Address �7� <br /> C Owner - Address ,S'� (' �-- fCl,,r7V_oe! <br /> OF <br /> U Firm Partners, Addresses and Telephone Nu bers _ <br /> a Business Telephone No. T 7— � <br /> C P �"' Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) sfr' .� Title �� � �� Date IS®7 # <br /> Please check Applicable Category(1-7)and Fill in the Required Information CLAIRE C.t•'S SLP:T`C & SE�IVER SERVICH ! <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 SO• 0+0 i' Stockton Calif. 95205 <br /> For July 1, June 30, 19 Disposal Sites 'y ContiL' 'ii a <br /> Description(Make/Yr., Color) #26r <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. <br /> 9.No. of Vehicles Stored nn <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 j <br /> 4. SANITATION PERMIT � <br /> Job Address/Location 1 <br /> OwnerA-� Address <br /> ; K SEPTIC TANCESSPOOL LEACHING FIELD SEEPAGE PIT PACKAGE PLANT ' <br /> E] I]PERMANENT ❑ TEMPORARY )4 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 y 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'doiie in accordance with.San Joaquin County <br /> ordinances, state laws, ann�dles and regulations of the San Joaquin L cal Health District Y: ) <br /> APPLICANT'S SIGNATURE X CLPd-0,10EI" S177i ,,,v <br /> 2633 So. Oro. -kz S a ktcan, C 1if. 95205 <br /> f ps C, ttr ,,6a I u7177 <br /> FOR DEPARTMENT USE ONLY I <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 DATE DATE REMITTED AMOUNT DUE CHECKED , <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION - <br /> PLUS I <br /> PENALTY L h <br /> OTHER �, Y <br /> 40 <br /> OTHER <br /> q <br /> I <br /> r g 1t,�1�1�� 1113 -79a-91a 1011 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES-' --1601 E.HAZELTON'AVE.,P.O.Box 2009 <br /> )ST1�OCCKTON,CA 95201 - I <br />