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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAG ) <br /> LIQUID WASTE G <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District � <br /> 07 Business Name (DBA) 4_-, Address <br /> SraAy Address ' <br /> z Owner �° A^� hc' M Address P. d' 13o X b <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. y 3-V�/'� Emergency Telephone No. <br /> Contractor Licence No. �* `'�6 <br /> a L�B l9rr�%/�orr Title <br /> Date -k- 6-'�'9 <br /> L Applicants Name (Print) <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. License 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. ® SANITATION PERMIT s' <br /> Job Address/LocationA7'L-- Address /-5- 5 <br /> _�' Sf3 ' <br /> ner G616 Sy. eyIP- <br /> O - <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 1:1PERMANENT ❑ TEMPORARY ❑ NEW Df REPAIR 13 OTHER <br /> S. ❑ 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 /> Plana 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 IA .r-77vxL IEn A0 K �c .r3�'.oRoa�r ✓� e� <br /> I kerbby 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 eg at'ons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i FOR DEPARTMENT USE ONLY <br /> l Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &ReceivedREMyITuly 31 <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE t LA S. < o <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> 1 ca <br /> Receive by Date Receipt No. permit No. issuance Data Mailed Delivered r` <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16 .H ZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 1 ,I - <br />