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.E <br /> LIQUID WASTE <br /> Application is hrby to carry on business in the jurisdictional area of the Sar)�quin Local Health District i <br /> NBusiness Name (DBA) �. �, r L� Address d ! <br /> .9 Owneroce Z,L Address <br /> (J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - :51"1 Emergency Telephone No, <br /> Contractor Licence No. 7-,)-5-'5-_-z <br /> Applicants Name (Print) if d z_ e- fly- Title Date <br /> Please check Applicable Category (1L7)and Fill In the Required Information 4� <br /> 1. ❑ PUMPER VEHICLE PERMIT RrEGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites ' <br /> Description(Make/Yr., Color) �M <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 /> 1�, For July 1, June 30, 19 <br /> No. of Vehicles Stored iM <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I <br /> R.S.or R.C.E. Name I R.S. or R.C.E. No. <br /> Test Location �k BTest Date/Time Y <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location "� 'i C* A Jfl l <br /> Owner) T2` �G� 5 -:57i�. Address % CI <br /> V` SEPTIC TANK '❑ CESSPOOL!!M iRLEACHING 17,1EL'-D- JJ SEEPAGE PIT. ❑ PACKAGE PLANT <br /> ❑ PERMANENT i❑ TEMPORARY ❑ NEW ❑ RE AIR ❑ OTHER <br /> .6 - i <br /> 5. ❑ CHEMICAL TOILETS For JLf y 1, -June 30, 19 l <br /> Type Construction �I` Disposal Site r <br /> No. of Units MI6 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 -� .z. *' tNo. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Junei 30, 19 `SIZE: Less❑ Less Than 1,000 Sq. Ft.,i� ` []-More Tlian.1,000 5q._Ft. le" ". <br /> ❑ DRY CLEANING, Chemicals Used <br /> .., j <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 re ations of the San Joaquin Local Health District. i <br /> APPLICANT'S SIGNATURE X <br /> M J <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 & ceived By Jan ary 31 ❑ July 1 &Received By Z 31 <br /> .BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION J AMOUNT DUE' CHECKED 'I <br /> DATE ATE MITT D AMOUNT <br /> FEE /�5 ' of <br /> "7C> <br /> LESS ' <br /> PRORATION ,IN' <br /> PLUS <br /> PENALTY fir- <br /> OTHER <br /> OTHER <br /> e J <br /> 16761 �2, <br /> Received by` - Date .Y. Receipt No. Permit No - IsAuanceDate- Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES ITO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2Do9 STOCKTON,CA 95201 <br />