Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.., - <br /> �' � APPLICATION <br /> ... = n (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUI6 WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) A, OAIsN 5oR1 S Address .Pa Sc+x1174450 S7�e_,L 9- .-4 <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ,/-66- 76D 7 Emergency Telephone No. J <br /> Contractor Licence No. <br /> L Applicants Name (Print) F - � 001;r Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information p�- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) x� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. CAL. License Renewal No. AJ <br /> 1 <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 /> v, <br /> 3. ❑ PERCOLATION TESTI <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ,+a SANITATION PERMIT V <br /> Job Address/Location /r a-:�--�?- a-P-4 AJC 7- AL",r_7aR_.a eA <br /> Owner RU JeA VIAZAAddress� —r- <br /> 0 <br /> 0 SEPTIC TANK El CESSPOOL JX LEACHING FIELD tal SEEPAGE PIT ❑ PACKAGE PLANT <br /> SSI PERMANENT ❑ TEMPORARY ❑ NEW 1WREPAIR ❑ 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 /> e <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 County <br /> ordinances, state laws, and rules and regulations of the quin Local ealth District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee It Due: ❑ ANNUALLY ❑ PER UNIT ❑ PERSITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Judy 31 - <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED u AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY , . <br /> OTHER <br /> OTHER <br /> I <br /> Received by Date Receipt No Permit No. - - Issuance D e %ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />