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 /> sEpr6 � <br /> ENVIRONMENTAL HEALTH PERMIT 4 <br /> LIQUID WASTE <br /> Application II der by mad to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) 2 Toe— &—.A- �e/�7`�Pa S'e Ule,� -_ Address��O �� ���i4d�• S7`�<e� 0.� <br /> a Owner I�L � C P. wee S Address � ' �� / '0 1 Ve •r' C� e�,�. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. -Z p <br /> L Applicants Name (Print) 4' Title �I/c� Date�f � <br /> Please check Applicable Category (1-7) and Fill in the Required Information CLARtHICE!S SE I iC SEWER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 2 3 So. Oro ;3 Sloc on, Calif. 95205' <br /> For July 1, June 30, 19 Disposal Sites Pb GFS- 20-9 O� t;FEtgr��{E 2g]17h <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 I <br /> 4. SANITATION PERMIT � � �, <br /> Job Address/ ocation C <br /> Owner f Address <br /> ❑ SEPTIC TANK 11CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 13 TEMPORARY _ ❑ NEW REPAIR ❑ OTHER rf <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 1 <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 CapacityNo. Units Served <br /> 7. 11LAUNDRY For July 1, -June 30,s19 M <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> P <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 th San Jo uin Local Health District.. <br /> I. <br /> CL:� E 'S Sci'iC U <br /> APPLICANT'S SIGNATURE X S ,'TR SERVICE <br /> 2c;; So, O;p � St0c6'ton Calif. 95205 <br /> �} '-- 209 Contractor's i_ic.�#cfi71ZA <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 0 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 F <br /> FEE S <br /> i <br /> LESS <br /> PRORATION © 1 Q z 7 <br /> PLUS <br /> PENALTY <br /> OTHER LO <br /> b <br /> OTHER <br /> Vcl 1 ED <br /> Received by Date: Receipt No. Permit No. Issuanc 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 /> �"` — <br /> rodl <br />