Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> A• <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE i <br /> LIQUID WASTE ' <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA) As L3ew_-5-niia-nya 1.1 Address 1 2-4- EY AVAP-44 0 �'� � <br /> aOwner Address <br /> J.Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. !& 9 7/ Emergency Telephone No. ; <br /> Contractor Licence No. 7 <br /> L Applicants Name (Print) FAA YD &7400J2 Title X57— Date '� z <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 p <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> 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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 04 SANITATION PERMIT <br /> Job Address/Location 37.3r aAA,Jl ��CA'7 A) - <br /> Owner—ARA a- AP-i Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ 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 /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served sl <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 and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X tL <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received.ey July 31 <br /> REMIT <br /> BASE EXPLANATION KILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> k r DATE DATE REMITTED AMOUNT <br /> F FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> -PENALTY 'L <br /> OTHER ✓ Y <br /> Y <br /> OTHER 1 <br /> Received by Date Receipt No. Permit No. I suance i ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.-HAZELTON AVE.,P.O_Box 2009. . ST.00KTON,CA 95201 <br />