Laserfiche WebLink
letea. ene aurc +.,v.1.. . <br /> Applications Will Be Processed When SuAPPLProperlyICATION � <br /> SEPTAGE <br /> (Far Nan-Transferable,Revocable,and Suspendable) € <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WAS?E <br /> Appiicat'on is her y made to carry on business in the jurisdictional area of the San Joaquin Local Health Districth , <br /> i <br /> S Address O <br /> NBusiness Name (DBA) Address r <br /> z Owner <br /> % <br /> Firm Partners, Addresses and elephone Num ergs Emergency Telephone No. <br /> aBusiness Telephone No. <br /> "-- 1 <br /> J Contractor Licence No. z Title f T� _7 0 Date <br /> � � i � . <br /> Applicants Name(Print) p� <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, <br /> June 30. 19 ( Disposal Sites � <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> CAL. License No. .41 <br /> Serial No. Gal.,Weights &Measures No. <br /> III <br /> Capacity <br /> Equipment Parking Address <br /> l z, ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> k 3, ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S.or R.C.E. Name t Test Date/Time <br /> Test Lo on <br /> [ 4- LR'SANITATION PERMIT s �� T <br /> f Job Address/Location ' S SS <br /> Address ❑ PACKAGE PLANT U} <br /> Owner El PIT. <br /> �. 19 [3L'�LEA <br /> SEPTIC TANK CESSPOOL CHING FIELD RREPAIR ❑ OTHER T <br /> ❑ TEMPORARY <br /> 11 NEW <br /> R--PERMANENTw <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 1Disposal Site <br /> . Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location I No. Units Served <br /> Plant Capacity <br /> . 7- C1 LAUNDRY For July 1,-June 30� 19 <br /> a More Than 1,000 5q. Ft. <br /> SIZE: C3 Less Than 1,000 Sq. Ft., <br /> ❑ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> ' plication and that the work will be done <br /> I hereby certify that I have prepared this apin accordance with San Joaquin County <br /> ,p ordinances, state laws, a rules and regulations of the 5 Joaquin Local Health District. <br /> l. , <br /> APPLICANT'S SIGNATURE X <br /> k, FOR DEPARTMENT USE ONLY ` <br /> � REMIT <br /> R.., Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑H PER SITE ,.»❑`EACH '❑.January 1 Received By January 3t AMOUnNTJDUE uly I &ReceivCeHEM;T d By July 31 <br /> _ BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> O� r <br /> 4 FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER + I <br /> Delivered, <br /> Iss ante at Mailed <br /> r 'Receipt No. Permit No- GA 95204 _ w <br /> Date f <br /> 1604 E.HAZELT VE.,P.O.Box 2009 STOCKT , <br /> Received by r E r` <br /> APPLICANT—RETURN ALL COPIES TO: ENYIRONMENTAL HEALTH PERMIT/SERVICES- <br />