Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. j <br /> A 7 <br /> APPLICATION W� <br /> t " r <br /> (For Non-Transferable,Revocable, and Suspendable) rSEPTAGI� <br /> n , <br /> ENVIRONMENTAL HEALTH PERMIT �� ? <br /> LIQUID WASTE r�0ii <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Manteca Sportsmen Address 30261 S Airport Way. r <br /> z Owner same Address <br /> C <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. 209-823-2350 Emergency Telephone No. 823-79 9 <br /> Contractor Licence No. Manteca Plumbing # 186808 <br /> L Applicants Name (Print) Associated Engineers & Planners,IncTitle nPsign Engineers Date 0Q79 <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 /> Serial No. CAL. License No. CAL. License Renewal No. 7 <br /> Capacity Gal., Weights & Measures No. d <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 /> 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 30261 S. Airport Way, Manteca <br /> Owner Manteca Sportsmen Address same <br /> 19 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT d <br /> ❑ PERMANENT ❑ TEMPORARY 11NEW 11 REPAIR 11 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 /> 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 San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Manteca Plumbing Li c. # 186808 , <br /> BY; Associated Engineers and PlarpVrs, Inc. --b- Associate �. <br /> "7 <br /> FOR DEPARTMENT USE O LY5123-233 0 <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT ElPER SITE 11EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE � ;� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 5 <br />