Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> n APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT 5EPTAGE <br /> LIQUID WASTE <br /> A licati r er b m de to car n busipess in the isdictional area of the San Joaquin Local Health District <br /> F Business N (DBA) C��t�f ��s ��c I Mar l��az Address -G6 13ur7c 'y RYe <br /> z Owner ! rM e��G' Address <br /> a ' <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. g� �- � Emergency Telephone No. <br /> Contractor Licence No. y39/$ <br /> L Applicants Name (Print) IAS CA9GIle Title Date f <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. Lioz—.se Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> i No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST l <br /> R.S. Or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location �P0. <br /> -Owner I/AR R y Address ;?-01-.71 V" R-Ne <br /> R SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY [$1 NEW ❑ REPAIR ❑ OTHER 1600 C.,Ie- Ic T latik <br /> 0 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 .Z It) fir, lll L�N� <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 �n <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> I 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 /> r <br /> 1 , <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqul3TCounty- <br /> ordinances, state laws, and rules and regulations of the Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 'A' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> • - �( cD�ATEEj DATE '/REMITTED AMOUNT <br /> FEE d1 .n "k- d�^t3 `�.• -v! �� ..rE� �^- <br /> LESS 1 <br /> t PRORATION <br /> PLUS <br /> i <br /> PENALTY <br /> y <br /> `F OTHER <br /> L <br /> OTHER <br /> de46eived by Date- Receipt No. Permit No. issuance Date Mailed Delivered - <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009,r STOCKTON,CA 95201 <br />