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 /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) F, ��l, C�� Soy Address /3 0, 13o,r- / IO /✓/oa��s7' <br /> aOwner �li►tTifav�. Address J�`''"T ' <br /> U Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 5 �3 "`���'� Emergency Telephone No. r <br /> � <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date �! <br /> Please check Applicable Category (1-7)andill in the Required InformationCP <br /> ` 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites s <br /> Description(Make/Yr., Color) <br /> i Serial No. CAL. License No. CAL, Licc;-ise 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 /> i ' <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. 0 SANITATION PERMIT �1 <br /> t Job Address/Location <br /> Owner f�� � -® <br /> 3 �.9 A<t~ ,q _ Address I3;'elw 4 h i <br /> � <br /> SEPTIC TANK ❑ CESSPOOL 13 LEACHING FIELD 11 SEEPAGE PIT El PACKAGE PLANT ` } <br /> F ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER �t <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 /> r Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 6 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I 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 San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ems!/ if Lt <br /> --, FOR DEPARTMENT USE ONLY - !? <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT LSPER.SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 - <br /> BILLING REMITTANCE $ REMIT <br /> 1 BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKEp <br /> AMOUNT <br /> FEE <br /> r LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 4 <br /> OTHER <br /> OTHER - - - { <br /> Received by ate I Receipt No. - Permit No, - Issuance Date M >led Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,.P.O.Boz 2009 STOCKTON,CA`95201 <br /> r <br />