Laserfiche WebLink
?�. ,pplicalions Wi11 Be Processed When Submitted ProperlyCompletes. be sure iooign In�.,NN ..a.... <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE y <br /> LIQUID WASTE <br /> Application is h eby made to ar on bust ess int e' isdi},tional area of the San Joa uin Loc alth Distt , <br /> ,,Business Name (D A) J <br /> �Fyu Address <br /> z Owner Jl— Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbe <br /> Z t7 57 Emergency Telephone No. <br /> EL Business Telephone No. <br /> j Contractor Licence No. J/ <br /> Title Date <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required nlormaiion <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) _ - <br /> CAL. License No. CAL. Lic:.�sse Renewal Na. <br /> Serial No. <br /> f Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> ` No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> k R.S. R.C.E. Name R.S. or R.C.E. No. <br /> or <br /> Test Loeaation Test Date/Time <br /> 4. 2SANITATION PERMIT J <br /> Job Address/L9cation Gi <br /> 7 r <br /> Owner �� -�-' .� Address ' _j <br /> ❑ SEPTIC TANK El CESSPOOL ❑ LEACHING FIELD ❑ ❑ PACKAGE PLANT 4— <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW , tEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> Where Certified <br /> Operator Name <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 Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 regulations of t an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -�—�— <br /> FOR DEPARTMENT USE ONLY <br /> f 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 /> DATE DATE REMITTED AMOUNT r <br /> 0 J f <br /> 1 C <br /> FEE <br /> LESS <br /> PRORATION <br /> v <br /> PLUS z <br /> PENALTY <br /> OTHER <br /> OTHER I <br /> Received by Date Receipt No. Permit No. Is uance ate Mailed Del e d <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES '1601 E.HAZELTON AVE., P.O.Box 2009 STOCKTON,CA 95201 <br />