Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Or Non-Transferable, Revocable, and Suspend ScE T _E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE �Dis�tr�ic� <br /> Application is heereby made to carryonbusiness in the jurisdictional area of the San Joaquin Local e <br /> rn Business Name (DBA)�� /�-✓�pn>�r�r CO. Address <br /> a Owner Address 'uf L+� -r-.4 pS-_3 3LZ— — <br /> Firm Partners, Addresses and Telephone Numbers -- <br /> aBusiness Telephone No. Emergency Telephone No. -- <br /> Contractor Licence No. <br /> �Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7) and FIII 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 <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ FACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER /1- <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 `elti r�v7pl oGl� 7 <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. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. <br /> HomeowrleTor itcense d agent's signature certifiesthetonowing:"1 certify that inthe performanceof thework forwhichthis permit is issued.I shall not employ any person <br /> in such manner as to become subject to workman's compensation laws of California" <br /> Contractor's hiri" or sub-contracting signature cortme, the following: "i certify that in the performance of the work for which this permit Is issued,I shall <br /> employ persons subiect to wcrkman's compensation laws of California." <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 - - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING - REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> p / / ` AMOUNT <br /> FEE - CL / ,2(, �J <br /> LESS // <br /> PRORATION !C� !/114 <br /> PLUS <br /> PENALTY r <br /> OTHER /% a <br /> OTHER ! <br /> Received by Date -Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />