Laserfiche WebLink
ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sig The Application. <br /> APPLICATION <br /> 1 _ (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH,PERMIT SEPTAL ,g <br /> ! LIQUID WASTE r r <br /> r �� <br /> Application ishereby`ade to carryon business in the jurisdictional area of the San Joaquin Locai Health District <br /> H Business Name (DBA)—I')r-Li/_GAddress <br /> a Owner " <br /> Address <br /> j Firm Partners,Addresses and Telephone Numbers <br /> aBusiness•Telephone No., <br /> _ Emergency Telephone No. <br /> J Contractor Licence No. <br /> L Applicants Name (Print) A <br /> Title 4�C*- 4 Date l <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. <br /> CAL. License No. CAL. License Renewal No. <br /> Capacity Gal„ Weights&'Measures No. <br /> Equipment ParkingAddress h, <br /> 2. ❑ PUMPER YARD;, <br /> For July 1 - June 30, 19 '. -• k <br /> No, of Vehicles Stored 't <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. J <br /> Test Location F Test Date/Time. - <br /> 4. ;4SANITATION PERMIT , <br /> Jab Address/Location - <br /> Owner _ — <br /> Address ,�: <br /> I- SEPTI_C,7 NK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT _ --P .TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL_TOIL ETS For July_-1,.:.June_30,_1.9. +� l <br /> Type Construction >. ( Disposal Site _ - <br /> w .,No. of Units - f Equipment Storage/Cleaning Location(s) y <br />` 6. ❑ PACKAGE TREATMENT.PLANT For July 1, -June 30,194" . <br /> Operator Name– 'w _ <br /> + Where Certified <br /> Plant Location <br /> Plant Capacity1 r- �---- ----, �' <br /> No. Units Served I <br /> 7. ❑ LAUNDRY: For July 1, -Jun�_30,19- . <br /> ��+ i <br /> SIZE: ❑ i],ess,1•han 1,000 Sq. Ft. ❑ More Than 1,000 Sq.`Ft. <br /> o- <br /> ❑ DRY CLEANING;-Chemicals Used%AmOUnt/Mo. i <br /> I t <br /> .I hereby}certify that I have p pared.�hls„application and that the work will be done in,accordance r lith San Joaquin County p <br /> ordinances, state laws;and-rules.and r tions f the-San Joaquin ct/, <br /> ,Local Health Distrij Ell r r, t <br /> APPLICANT'S SIGNATURE X �. _. ) r <br /> .r4rN <br /> " pFOR DEPARTMENT USE ONLY <br /> Fee is Due: El ANNUALLY .� ` "-' <br /> IN, A.. ( I <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received B anuar <br /> - � Y 31 ❑ July t &Received By-July 37 <br /> BASE XpLANgTiOIV. x �ILLING M REMITTANCE $ �- REMIT <br /> DATE +S `� AMOUNT DUE-CHECKED { <br /> _ DATE REMITTED .- <br /> - (? _ ' „s• AMOUNT <br /> FEE <br /> LESS r <br /> PRORATION a l <br /> PLUS Yf <br /> PENALTY <br /> OTHER <br /> OTHER i <br /> ReAPPLICby Date - . Receipt No Permit No. ! suance bate <br /> =-Mailed Delivered -- <br /> ., _ ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES <br /> 1601.E HAZELTON AVE.;.P.O.Box 2009 STOCKTON,CA 95201 <br />