Laserfiche WebLink
4: Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />` u APPLICATION <br /> T (For Non-Transferable, Revocable, and Suspendable) # <br /> ENVIRONMENTAL HEALTH PERMIT l SEPTAGE <br /> LIQUID WASTE <br /> f Application is her by ade to carry on business in the jurisdictional area o San Joaquin Local Health District <br /> y Business Name (DBA) -� Address'', 7--CA _ <br /> a Owner J5/&('4F9 Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Q. Business Telephone No. i� ' Emergency Telephone No. c <br /> Contractor Licence No. c5t _ <br /> L Applicants Name (Print) G Title ct!/i/ Date — I <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 -1 Disposal Sites <br /> Description(Make/Yr., Color) <br /> r. <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity l; Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD , I <br /> For July 1, June 30, 19 l <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. v <br /> Test Location = - --- Test Date/Time <br /> 4. ❑ SANITATION PERMIT ✓�'~ - 1 <br /> Job Address/Location 1A / W -/f I Grr>✓C?' L1 <br /> -Owne _-� _. �,;,, „f -Ad dres"s' <br /> PTIC TANK D CESSPOOL 1~ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT C1 TEMPORARY 11 NEW 11 REPAIR ❑ OTHER <br /> 5.'-0`CHEMICAL-TOILETS `For'July 1;-'Jude 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 s <br /> Plant Location <br /> I <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/Amount/Mo. ,. <br /> I hereby certify that l have prepared-this applica`tiori and"that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatigons oftfieASan JQpquinrLocal Health District. .� <br /> �. <br /> APPLICANT'S SIGNATURE X 'Ir^ •` � -��~ """� ""��""' """� T' """� " ;• <br /> FOR DEPARTMENT USE ONLY N` as <br /> Fee Is Duem❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE it?� EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> I DAT DATE --REMITTED AMOUNT <br /> v <br /> FEE .C�S a ; ' <br /> LESS II <br /> RORATION A' <br /> PLUS <br /> PENALTY - - <br /> OTNER.; r <br /> OTHER I� <br /> Q„1 <br /> Received by Date Receipt No. - Permit No. Iksuancfi Dati§ Mailed Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />