Laserfiche WebLink
APPLICATION a <br /> �. (For Non-Tranalitrsible, Revocable,And Suspendable) SEf fP."E <br /> fe ENVIRONMENTAL HEALTH PERMIT <br /> t LIQUID WASTE <br /> Application is hereby made to carry on business in the Iurisdic_Uonat area of the San Joaquin Local Health District <br /> Business Name (DBA) WISH- GON�I -'l7ord A�AfiY)6F,NF....>��' __ Address_5_�J Zp3 , OA6.a r eA <br /> QOwner /�Li�tfi-Gr1� Address—IO-35_b_-_LOPEWocDPI.A4L-E <br /> g Firm Partners. Addresses and Telephone Numbers _IQA4 `�`^_t.-_q Ir-4--, zepor S. AA egr"E S'TkrJ <br /> Business Telephone No. 9y%-154 S _ Emergency Telephone No _ <br /> j Contractor Licence No. <br /> i Applicants Name(Print) Title -- .__ _ Dale_ _ <br /> Please check Applicable Category(1-7)and Fill M the Required Information N <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) lC)H I <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 hemlcal Toilets Stored <br /> 3. 'PERCOLATION TEST <br /> R.S. or R.C.E.Name _-_14TR.4[.-L G- 1,1r R.S.or R.C.E. No. <br /> Test Location —_3Z5C7 Gn V E9-i"31 < I STK-0 Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner . ......__ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units _. _._ Equipment Storage/Cleaning Locafion(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19____ <br /> - <br /> Do�iet a(r1e Where C tI/I d 1_ s. ` T ...I. . ' )tor <br /> plant 0181 - Nl la� -�p G01«.c f GOO "-<•l 'lr lc <br /> Plant Capacity- _ <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19___._ ----- - -- �% �Ko x,- <br /> SIZE: 13Less Than 1,000 Sq.Ft., 13More Than 1,000 Sq. Ft. -3:D57 Por d' <br /> ❑ DAY CLEANING,Chemicals Used/Amount/Mo. <br /> Mlaneawrwrer A <br /> hromledapetlt'a tlonsturlt eMNbthe e to"o"l" M <br /> p:"I CediM Ihn!In glnlMrivmanc9 n!'hp wor4lrr wrh thio P^rmN It i<annd,I-hall not nmpiny any pprvre Vf�` <br /> In suck manner es to M1ecoms suM1)eH: le wnman's rompensa!Isn lata cl Ca <br /> Contracter-1 hiring or Erb-omtraeting.signature oartIll ir tho foHowin r: I rmIlly Ilia!in the prrlhrm ince rf the work for rohlth Ibis reriell is isenrd,I shall <br /> employ persons subject to workman compensation laws of Calllotloa.' <br /> I hereby certify that t have prepared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances, stale laws,and T{Ileg end eguletio of th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �•/L(//�/ ` <br /> l./ ki Se" )a s, <br /> FOR DEPARTMENT USE ONL <br /> Fee to Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d eceived By January 31 ❑ July I a Received By July 31 <br /> -- --- - - -- — ------- - FIEMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE nEMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS . <br /> PENALTY <br /> OTHER <br /> 01"FR <br /> _._ /�7� <br /> Y On neepipl N2 Permit No laulancn 6nle W,lird Orlivrrpd <br /> APPLICANT-RETURN ALL COPIes TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Heel E.HAZELTON AVE.,P.O.Do%2009 STOCKTON,CA 95201 -- <br />