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 /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 92 -.3 <br /> Application 's hereb made t arry q-npysiness in the jurisdictional area of the San Joaquin Lo e <br /> Business Name (DBA) K +� j Address ZrZ� <br /> cOwner Imo ` - - —-- Address L0 R�. <br /> y Firm Partners, Addresses and Telepjione Nu bers <br /> aBusiness Telephone No. — �X33 9 Emergency Telephone No. <br /> j Contractor Licence No. <br /> a Applicants Name (Print)d • Title " Date Ztr <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 /> Equipment Parking Address — - - - - - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. f Chemical Toilets Stored <br /> 3. -4 PERCOLATION TEAT _ �.r <br /> R.S. or R.C.E. Name j ~&ftd i• a/I✓2 R.S. or R.C.E. No. 3 <br /> Test Location / ^wor* ARM%- -- Test Date/Time ;17 f - <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 /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 . <br /> Type Construction Disposal Site <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 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 tha the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules nd regul ns of S oaquin Local ealth District. <br /> APPLICANT'S SIGNATURE X / <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Jan a 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING t� E $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ..� <br /> / �i / „ cam tV,,e7 o <br /> LESS <br /> PRORATION <br /> PLUS -- -- - --- <br /> PENALTY <br /> OTHER `— <br /> OTHER -_ - - - — <br /> Received by Data Receipt No. Permit No. Issuance 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 />