Laserfiche WebLink
F Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, — <br /> �. APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH .PERMIT SE=PTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the an Jo quin Local Health Distri t <br /> } rn Business Name (DBA) Address Q' 7 5V �TK� �- <br /> t z Owner <br /> a ,- Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> ` a Business Telephone No. <br /> Emergency Telephone No. <br /> r Contractor Licence No. Z <br /> Applicants Name (Print) ,STitle Z5,GZ, Date :4r.7 <br /> Please check Applicable Category (1-7)and Fill in the Required Information M <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) `� 1 <br /> For July 1, June 30, 19 Disposal Sites (V�1 <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address I r <br /> f ` 2. 13 PUMPER YARD <br /> i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored a <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ` <br /> Tel Lvc �n Test Date/Timer <br /> 4. . SANITATION PERMIT <br /> Job Address/Location -JEOCV <br /> O Z <br /> Owner 4 Address <br /> 2'SEPTIC TANK. ❑ CESSPOOL 9-LEACHING FIELD <br /> El SEEPAGE PIT 11 PACKAGE PLANT �l <br /> �ERMANENT ❑ TEMPORARY EI''N'EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ]t7 <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 r a <br /> Plant Location _ <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 r <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> d <br /> I herebycertify that I ha I <br /> Y prepared this application an that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d rules an gulatio f t an Jo quin Local Health District. <br /> APPLICANT'S-SIGNATURE <br /> ' FOR DEPARTMENT USE ONLY <br /> Fee IS DUe: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH 1:3 January 1 &Received By Januar ~ <br /> y 31 ❑ July 1 &Received By July 31 i r <br /> s BASE ' .EXPLANATION BILLING REMITTANCE $ REMIT <br /> - DATE DATE REMITTED AMOUNT DUE CHECKED 4 <br /> AMOUNT y <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS i <br /> i PENALTY <br /> I <br /> OTHER <br /> sr <br /> OTHER <br /> Receivedby Date 3`' \\ <br /> - t Receipt No. Permit No. Issuanc Date Mailed Delivered } <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box'2009'= STOCKTON,CA 95201 <br />