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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> t _ T LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,�Bu`siness Name (DBA)_P%.off» Address <br /> z Owner' � t r� , <br /> Address 2 S7 �g {- ; a v\ 6 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. '93 $`- 357 Emergency Telephone No. <br /> Contractor Licence No. 1 � <br /> LApplicants Name (Print) 15�- Ily\ <br /> - Tkfe � er' pate <br /> Please check Applicable Category (1-7)and Fill in the Required Information 1' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) y <br /> 4 Serial No. CAL. License No. <br /> I CAL. Lic;.;ise Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address a <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I 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 /> p 4. SANITATION PERMIT j <br /> . . �. <br /> r Job Address/Location .Z �fS �- t( <br /> ( !a _{Mayes ' ; N/S� t1ti�Y>r <br /> Owner_ta: * G <br /> ` ��--��'�� e— Address Am 1 <br /> ❑SEPTIC TANK ❑ CESSPOOL UPTEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAINT <br /> [ErPERMANENT ❑ TEMPORARY ❑ 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) 1e <br /> 6. "❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> 1 <br /> Plant Capacity No. Units Served <br /> j 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 /> r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa C ty <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 76G r f <br /> I <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 I <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE � � AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> Ii <br /> OTHER <br /> Received by Dat Receipt No. Permit No. Issua D <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1807 E.HA ailed <br /> Delivered <br /> LTON VE.,P.O.Box 2009 STOCKTON,CA 95201- <br />-a ' <br />