Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sil�o Sign The Application. t <br /> APPLICATION NOV 25 IV <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT t .�` SSE TAGE <br /> LIQUID WASTE �N� i1 A #L �,O ,;�� <br /> HEALTH DISTRICT <br /> Application is hereby made to cayy on business in the jurisdictional area of the San Joaquinocal Health District <br /> to Business Name (DBA) Cad ew e)_neere SI—. Address 4200 Aen« A do /. . Z64ai k, Cc1(r t g j/6 t <br /> aOwner Address l <br /> Firm Partners, Addresses and Telephone Numbers <br /> r <br /> CL <br /> Business Telephone No. - Emergency Telephone No. i93�24Q 7 <br /> Contractor Licence No. 73 7 7 3 <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill In the equired Information T� <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 <br /> Joh Addres /Location � eA 9de ] <br /> Owner Sfa �� Ea�S3�t 76 z4) Address �reqR <br /> SEPTIC TANK 11 CESSPOOL IeLEACHING FIELD 11 SEEPAGE PIT C1 PACKAGE PLANT <br /> DIPERMANENT ❑ TEMPORARY MINEW ❑ 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 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. } <br /> 1 <br /> t <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 an regulations of t Local oca! Health District, VAPPLICANT'S SIGNATURE X �. <br /> FOR DEPARTMENT USE ONLY/` I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE % a <br /> LESS F <br /> PRORATION [ <br /> PLUS P <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> 13�� l 3a t 2 er <br /> Received by Date - Receipt No. .Permit No. _ Is uan D e Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11 01.E.HAZ VE.,P.O.Bo:2009 STOCKTON,CA 95201 _ <br />