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 SI=PTAGE <br />!� LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> JiBusin ame (DB Address <br /> wne �- ��m Address rr <br /> a <br /> Firm Partners, Addresses and Telephone Numbers a�!H <br /> I'LL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No._ <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information C> <br /> ,1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) fn <br /> For July 1, June 30, 19 Disposal Sites V <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Li":ise 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 /> eVLationTest DateTTime <br /> 4. NITATION PE MIT <br /> _ ob Address/Location, - r <br /> Owner � _. Addr s_ <br /> i <br /> SEPTIC TANK ❑ CESSPOOLr LEACHING FIELD EEPAGE PIT 11 PACKAGE PLANT' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW I �EPAIR ❑ OTHER <br /> "3. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units ( Equipment Storage/Cleaning Location(s) f <br /> 1 <br /> 6. ❑ PACKAGE TREATMENT PfLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location 4 V <br /> Plant Capacity r No. Units Served ) <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r <br /> { SIZE: ❑ Less Than 1,000 Sq. Ft., 131 <br /> More Than ,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I 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 ru es and regulations of the San Joaquin Local Health District. I <br /> APPLICANT'S SIGNATURE X" <br /> ( ; I <br /> . , FOR PEPARTMEN7 USE ONLY <br /> Fee Is Due: ❑ ANNUALLYtQPER UNIT ❑ PER SITE ❑ EACH_ ❑ January 1 &Received ey January 31 ❑ Julyt &Rec ed By July 31 <br /> — - - ------ -- - - EMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE ECK <br /> DATE DATE REMITTED <br /> FEE <br /> L/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY <br /> { OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />