Laserfiche WebLink
ApplicationsWill Be ProcessedWhen Submitted Properly Completed. Be SureTO Sign The Application. <br /> APPLICATION <br /> Pref Non-Transferable, Revocable, and SuspendabP. <br /> ENVIRONMENTAL HEALTH PERMIT v SEPTAGE <br /> LIQUID WASTE <br /> Application is by rrLade tm in the jurisdi 'onal area of the S n,J.oaq/1ui�n Local Health District <br /> „ o c rry on us <br /> Business Name (DO — Q+' Address r--�'C 76 7 <br /> ? 61, <br /> Owner Address <br /> s <br /> Firm Partners, Addresses and Telephone Numbers <br /> as Business Telephone No. _;; Emergency Telephone No. <br /> Contractor Licence No. 22 42 g <br /> 01 <br /> ZZ— <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Inforrillation V U\ <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 /> 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�Lopshon Test Date/Time <br /> 4. Ur SANITATION PERMIT <br /> Job Address/Loc n <br /> Owner ' Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD � S�AGE PIT ❑ PACKAGE PLANT ✓ <br /> ❑ PERMANENT ❑ TEMPORARY 11 NEW Lk'REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units- - -- -- -E-quipmentStorage/Cleaning-Locations) -- -- -- -- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <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 I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and ruigs and regulations Of Sa Joaquin Local Health District. jl <br /> APPLICANT'S SIGNATURE ' _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Reced By/January 3;,-7A July 1 6 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE I AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> X311 � �l <br /> Received by Date Receipt No. Permit No. lasu Dae Mailed O iv <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 B.HAZ LTON AVE.,P.O.Bea 2009 STOCKTON,CA%101 <br />