Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. J <br /> . . APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> l�� 1 LIQUID WASTE <br /> Application is here y made to carry on business in the jurisdictional area of the San Joaquin Local Health District f <br /> ,;Business Name (DBA) >Q 4 nnrr S A_ Se%z,S Address !'o Box zym <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. yG G ^ f b O 7 Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) ©� J�¢���r-S Title �r�/1?' 7�1/ Date f� /-a - 2 <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 171 <br /> Description(Make/Yr., Color) <br /> 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 /> 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 /8 <br /> Owner &&PAL Q 61(s o xl Address =2 / T <br /> ® SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> I� PERMANENT ❑ TEMPORARY SSI NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site O <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 regu ations/off the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE � ���?efa44 m �' <br /> Com` # <br /> f <br /> i <^ <br /> FOR DEPARTMENT. ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EA (`January 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 �t <br /> PRORATION <br /> PLUS ,.: <br /> PENALTY <br /> ai <br /> OTHER <br /> OTHER <br /> --79 - q8- liz 77 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO A 95201 <br />