Laserfiche WebLink
",,Applications Will Be Processed When Submitted Properly Completed. Be SureTosign tneAppllctltlU" <br /> APPLICATION <br /> i 4E (For Non-Transferable, Revocable, and Suspendable) SEP7pGE <br /> II ENVIRONMENTAL HEALTH PERMIT ' <br /> ii LIQUID WASTE <br /> Application hereby made to carry on business in the jurisdictional-area of the San Joaquin Local Health District <br /> Business Name (DBA) <br /> aOwner- <br /> 2 <br /> wner V Firm Partners, Addresses and Telephone mbers <br /> M Business Telephone No. 6 � Emergency Telephone No. <br /> 4 li <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> - Title � Date I'I <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> t <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License Na. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. � <br /> ;i <br /> Equipment Parking Address - <br /> 2. `❑ PUMPER YARD 1 �+ <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST _ <br /> R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> F Test Date/Time <br /> Test Location - <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Ownern/1� Address <br /> ,,....__, � — ' ���� PLANT <br /> I�SEP ,,--,, <br /> TIC TANK ❑ CESSPOOLS �LtACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE <br /> ❑ <br /> t ❑ OTHERPERMANENT ❑ TEMPORARY ❑ NEW ❑•REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July <br /> Type Construction Disposal Site - --- __ <br /> Equipment Stora a/Cleanin Location s)_ <br /> No. of Units9 g` ( - • ---- - --- -.. r _ �' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name F 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 ThaIr1;000-SO-Ft:— - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo- 1 <br /> r' <br /> a <br /> . ps <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 re ulations of thp San Joaquin Local Health District. ". a <br /> APPLICANT'S SIGNATURE X r e <br /> i. FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ uary 1 &Received By January 31 Cl 1 8 Received 8y July 31` <br /> ' - _ - REMIT � <br /> BASE EXPLANATION DATE <br /> REMI ANGE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> �•�" t /Y <br /> PRORATION <br /> PLUS G <br /> PENALTY <br /> OTHER ! - # - <br /> I # <br /> OTHER <br /> 0 ItPE/�a/ r <br /> ^ <br /> ` Received dy Date Receipt No ' Permit No ?4E.11AZELTON <br /> u nC6 ate Mailed Delived'APPLICANT—RETURN ALL COPIES TOi' ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1AVE.,P.O.Bax 2009:. STOCKTON,CA 95241 <br /> 17, <br />