Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION <br /> (For Non-Trinslerable,Revocable,and Suspendable) <br /> EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 16 <br /> LIQUID WASTE <br /> t' Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 4. <br /> s y Business Name (DBA) Address <br /> aOwner A-/,t` Address / �"s <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> i Contractor Licence No. <br /> Applicants Name {Print) Wee Title d�y". Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> r For July 1, June 30, 19 Disposal Sites r€ <br /> Description(MakeNr., Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. _N <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> r 2. ❑ PUMPER YARD <br /> i For July 1. June 30, 19 <br /> No, of Vehicles Stored <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 /> t 4. 0 SANITATION PERMIT I� <br /> ( Job Address/Location ��y�✓� �r �'ti �� '�/�LOtY <br /> Owner 7' ��•�� Address ��l`��S /�7� . �.9iY G/ •���•�+`o/r <br /> SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT E <br /> IM PERMANENT ❑ TEMPORARY 13 NEW ❑ REPAIR ❑ OTHER y �. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Is <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) .. i� O <br /> �f <br /> r 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 it <br /> Operator Name _. Where Certified <br /> Y <br /> Plant Location - <br /> Plant Capacity No. Units Served * " <br /> 7. 11 LAUNDRY For July 1, June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. l e <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. J <br /> P <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 r les and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> F Fee IS Dile: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received-By July 31 <br /> r REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ y. AMOUNT DUE CHECKED <br /> DATE DATE REMITTED L� AMOUNT <br /> FEE v1 1; ` <br /> LESS µ <br /> PRORATION <br /> PLUS V` <br /> PENALTY <br /> OTHER f/J <br /> I^ OTHER <br /> r � <br /> x Rued by tate Receipt No. Permat No Issuance Date Mailed Delivered <br /> v APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 - STOCKTON,GA 95201 <br />