Laserfiche WebLink
Applications Will Be i �ssed When Submitted Property Completed. Be a To Sign The Application. <br /> APPLICATION _ <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appiication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) - Address _ <br /> i Owner :it0. Address 'L(�_hICIJ-'-[kiC_tJr-F_r <br /> 7 Firm Partners. Addresses and Telephone NumbersSti <br /> gerAeas Telephone No .czEmergency Telephone No. <br /> Contractor Licence No <br /> Applicants Name (Print) —WALZF-r9_IF-__ IC <br /> u_ _ Title _C IY N.-rn�WC I._�T_-�Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information c"_ <br /> i. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4-11 MA7nAE ry PLAX.A <br /> Fo- July 1 June 30. 19 __- Disposal Sites L.nDI ►c+��Ih11f� 9���,¢� <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 /> n <br /> For July 1. - June 30, 19 ._ Wks' <br /> No of Vehicles Stored <br /> No of Chemical Toilets Stored <br /> 3. 21 PERCOLATION TEST'4-18 MAir-w PSQAoDi,1 r:/1L-;FoS2NI!\ 7 <br /> PAIWDr R.0 E. Name YY(��11c2_ _�..uR71 Rdk=W R.C.E. No. <br /> Test Location e''t+� � -- <br /> a• C3SANITATION PERMIT n�_y4 Mt n�_ H est Date/Tim e73-c� <br /> Job Address,Locatlon (-� � <br /> Owner _ -� M 17=1 -_Z-K J <br /> ❑ SEPTIC TANK El CESSPOOL El LEACHING FIELD Address �"'❑ -- -7- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW SEEPAGE PIT ❑ PACKAGE PLANT <br /> 5- ❑ CHEMICAL TOILETS For .July 1, - June 30. 19 ❑ REPAIR ❑ OTHER <br /> Type Construetiew._ (disposal Site <br /> No of Jnits Equipment Storage/Cleaning Location1s) - ---- — <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1 - June 30. 19 - - -- <br /> Operator Name - <br /> Plant Location -- Where Certified <br /> Plant Capacity _ <br /> ❑ LAUNDRY For JulY 1, -June 30, 19 No. Units Served <br /> — _ <br /> SIZE ❑ Less Than 1,000 Sq. Ft.. ❑ More Than 1,000 Sq. Ft <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo <br /> -- - tom• <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 <br /> APPLICANTS SIGNATURE X <br /> Title S_i_Vi L 14Co wEE F Date T FOR DEPARTMENT USE ONLY <br /> 4-92- <br /> F@@ If Due: ❑ ANNUALLY ❑ PER UNIT <br /> ❑ PER SITE Cl EACH C3JanuaryB January t 8 R <br /> - -------- y January 31 ❑ July t b Receivetl By July 3. <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE - — - AMOUNT <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY - ---- ._--.—_--_-- <br /> OTHER -- <br /> OTHER -- - - - - <br /> t[ {j <br /> ceivea by Y L -��'� �C - __ <br /> Date ReceipN <br /> t O— Permit No --- -e— <br /> APPLICANT--RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Mailed t3elivered - <br /> 160T E.HAZELTON AVE..P.O R.,.mno <br />