Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign Ine Application. <br /> APPLICATION <br /> (For Non-Transiera4le;P.evocabie, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to arry ass in the jurisdictional area of the San Joaquin Local Health District <br /> rABusiness N e (DBA) Addres <br /> Owner drs -S � a-51''tCCz N / � <br /> OFirm Partners, Addresses a Tele oneumbers LO nlS4?9-RI OAS f AR� <br /> Qz 3 O'7 5 <br /> 'a Business Telephone No. o 3 1 Emergency Telephone No. <br /> d Contractor Licence No. _ <br /> Applicants Name (Print) c� -� ,�E-ATLn I �� Itle. OuJ ��- 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 /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Phernical Toilets Stored <br /> 3. ePERCOLATION TEST <br /> R.S. or R.C.E.Name <br /> atN <br /> 4i IaN <br /> Test Location Z5"�It�t fit. LOAI E�TR.E.E — SGf4�O tJ1 eDe Ima <br /> st <br /> 4. ❑ SANITATION PERMIT `\ <br /> Job Address/Location �1 <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 /> Nome Owner or licensed.gent's signetereaerd6asthetWlowing:"Ithatin Lhepertormancecf m",verk for which this permit is issued,l shall not employ any person <br /> In such manner as to become subject to workmac's compensatlpn laws cf.C iforRk• <br /> Contractor's h;ring or Sub-contracting sh,"tcn ran:" •Ideiiea: i cl�rlity Ihpf in Ike periermente Of IhewoM for wtlkh this permit Is Is3ved,l shall <br /> employ peroos out);el;i to wcrWaaa's ca:npcnsatiun lets of Latdot ir. <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 lavoand r d regulatios of the San Joaquin Local Health District. �/ <br /> APPLICANT'S SIGNATURE X ` ° _ C ER A Ly 7�C 1-L F, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> •�,, //p <br /> FEE - O -� .aI �'�I 3 /g �ZO <br /> LESS <br /> PRORATION <br /> PLUS I QO <br /> PENALTY <br /> OTHER <br /> OTHER <br /> zoz <br /> Receivern d by <br /> Date Dateo Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PE4iMIT/SEFrnCES 1601 E.HAZELTON AVE.,P.O.am 20418 STOCKTON,CA 95201 <br />