Laserfiche WebLink
Appli aC Tions Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> k APPLICATION <br /> 'r (For Nan-Transferable, Revocable, and Suspendable) SI PTAGE _J <br /> J� ENVIRONMENTAL HEALTH PERMIT 4 <br /> I LIQUID WASTE I <br /> Application is hereby m carry o Nil business ijurisdictional area of the San Joaquin Local Health Distr' t O <br /> y Business Name (DBA) _ , <br /> Address I"Chvr.c n <br /> r i Owner �' �^ Address �� <br /> Firm Partners, Addresses and Telephone Numbers <br /> ' a Business Telephone No. / R Emergency Telephone No. <br /> Contractor Licence No. r t- <br /> Applicants Name (Print) " Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> r 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 /> i <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> t R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locati 2 G 3 <br /> I. Owner >1 Address G S'- !^Fh dta <br /> ASEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT N <br /> ❑ PERMANENT [] TEMPORARY ❑ NEW ❑ REPAIR OTHER svYKr <br /> k 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 4 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 /> 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 /> y- <br /> I hereby certify that prep is application and that the work will be done in accordance with San Joaquin County <br /> ordinances, sta aws, and rules and re lati s he an J ui<:�Cal Health District. <br /> APPLICANT'S SIGNATU X. _ ~ <br /> FOR DEPARTMENT USE ONLY <br /> Fee_ Is Due: ❑ ANNUALLY ❑ PER UNIT WPER SITE ❑ EACH ❑ Jafnuar 1 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTAI'G $ REMIT <br /> BASE EXPLANATION 111111 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I <br /> I <br /> FEE ✓/ `7 <br /> o , <br /> LESS <br /> PRORATION <br /> k PLUS <br /> PENALTY -. <br /> E '16.-jOTHER <br /> OTHER <br /> ' s `7q-1CZ s 7 <br /> Received by Date. Receipt No -Permit No. _ .. mow, ssuance,-ate Mailed Deliv ed <br /> APPLICANT=RETURN ALL COPIES To-, ENVIRONMENTAL HEALTH.PERMIT/&EflYkCES":A"rx`�' ,^^Y60f19:HAZELTON AVE.,P.O.Box 2009 S T 79'12 01 <br />