Laserfiche WebLink
✓ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> la - <br /> APPLICATION - <br /> (For Non-Transterabie;Revocable, and Suspendable) SEP7AG>= <br /> AAA ENVIRONMENTAL HEALTH_ <br /> -_PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin:Local Health District <br /> m Busines me(DBA) Address <br /> z Owner Address �j <br /> 4 Q <br /> J <br /> Firm Partners, Addr sen d Tele hone,Numbers <br /> CL a Business Telephone No. Emergency Telephone No_•-- <br /> Q :- �. ' <br /> Contractor Licence No. m <br /> LApplicants Name (Print) Title - Date 1 1 <br /> Please check Applicable Category (1-7)'and Fill in the Required-Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICL <br /> For July 1, Juhe'30, 19 - - Disposal Sites <br /> Description(Make/Yr., Calor) <br />` Serial No. CAL. License NO. CAL. License Renewal No. . <br /> Capacity Gal.,Weights& Measures No. <br /> I 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 /> 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. SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> PLANT <br /> SEPTIC TANK ❑ ESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT � OTHER PACKAGE <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR <br /> OTHEFi l{ � �� �e` n <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. ❑ PACKAG BEAT N PLANT r July 1, -June 30, 19 <br /> Operator Nam Where Certified <br /> Plant Location s <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 /> °ral9o�^ <br /> �� n� :.igratrrr�rer�firsch- d � e <br /> Siiollananneres,to�QIrPrtsf)r�ih tn,ltCperformsnCeGffcWorkfor which IhIspermit I$lt5ued,!,L.J1gotor 1 ^s•T <br /> �oirtracto{c't�s11 xa er 4sSl ansr, r.g a f a t rtl ." 4-,.�r <br /> PJerr L "I Cecilly i}1i3I i�tiyC pEIf3S' (?f fl1C W051{ft'r Vi l`.T.,� n?` <br /> 9X10M,1.3.i�,5 C0113P�.�]�t1�l l}l i laws 01 al,larit IG. + <br /> 111I1CC <br /> ' . ' <br /> — T <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 he San Joa in Local Health District. _ , <br /> i APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> i s <br /> ..i. Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT` ❑ PER SITE ❑ EACH_ _ .❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> it REMIT <br /> BASE EXPLANATION BILLING REMITTANCE ` $ AMOUNT DUE. CHECKED <br /> �. DATE -DATE REMITTEDAMOUNT <br /> i FEE <br /> LESS — <br /> PRORATION <br /> PLUS ; <br /> PENALTY <br /> OTHER <br /> OTHER r , <br /> 7 :.:FL9-- <br /> Recetved t y Date Receipt No: Permit NO. Issuance Date Mae -Delivered <br /> - <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2069 STOCKTON,CA 9520E ' <br />