Laserfiche WebLink
APPLICATION <br /> Q "• ,r Non-Transferable, Revocable, and Suspendabl. <br /> ENVIRONMENTAL HEALTH PERMIT SE TAGS <br /> LIQUID WASTE <br /> Application is faereby made to arry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) : ' <br /> Address <br /> aOwner Address e <br /> Partners, Addresses and Telephone Numbers <br /> CBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. - <br /> a Applicants Name (Print) Title Date <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 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> FEquipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> , <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> Ro. of Chemical Toilets Stored <br /> . ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.of R.C.E.No. <br /> Test�Lo tion Test Date/Time <br /> tr e.J <br /> 4. SANITATION PERMIT ,� <br /> "Job Address/Locati n f 7 � . �/ ' ' —Y <br /> w1er Address 'F4'0 <br /> �� �SEPTIC TANK ❑ CESSPOOL LEACHING FIIELD 1 j*PAGE�PIT ❑ PACKAGE•fPLANT E <br /> PERMANENT ❑ TEMPORARY © NEW _w 1 6 REPAIR ❑ OTHER`,•'r. <br /> -5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> EType Construction Disposal Site N .! _ N <br /> ND. of Units Equipment Storage/Cleaning Location(s) .—ml� ' PC, <br /> F6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 t <br /> F("Operator Name - here..Certified <br /> Plant Location 4 <br /> ,""Plant Capacity No. Units Served ! # <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 r <br /> SIZE;: ❑ Less Than 1,000•Sq. Ft., ❑ More Than 1,000'Sq. Ft. " <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> F,L <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 ulations of the San Joaquin Local Health District. <br /> FAPPLICANT'S SIGNATURE X <br /> r <br /> FFOR DEPARTMEN USE O <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH a.ry 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING RE ANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> - DATE ATE REMITTED AMOUNT <br /> FEE t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Yq ? � <br /> Received by Date ReceiiA No. Permit No. - IS uanCe Daae Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SE VICES 160 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />