Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> u Non-Transferable, Revocable,and Suspendablk�111111110 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati er by made to carry Q9 bu In ss in theiurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) � Is �r`� �j�v -155- Address ASC iSu f To, •'�U� c� <br /> Owner _ ! yr1 (,.g(ZGtAddress " Clb <br /> Firm Partners, Addresses and Telephone Numbers 1 <br /> Business No.Telephone p '� � � �' ��� Emergency Telephone No. f <br /> Contractor Licence No. �y3�11 <br /> Applicants Name (Print) rn1 iR �12�t/r_ Title Date v <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 Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time .- <br /> 4. ❑ SANITATION PERMJ; <br /> Job Address/Location 1 �� � Q ` ' 0 <br /> Owner A.E. G/krr;I` Address /0 300 _ /_l twfty / !20 17jAA•7tt_✓1 O <br /> ❑ SEPTIC TANK ❑ CESSPOOL g LEACHINGFIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ,L <br /> Type Construction Disposal Site 00O it- , X' /u` F, 1 r-L- S<°J <br /> No. of Units Equipment Storage/Cleaning Location(s) N <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 0 <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 rules and regulations of the <br /> San Joaq Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT I$t PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -7 //6/30 3`7L 5 04PY51 -7 Ll <br /> Received by Date Receipt No. Permit No Issu rice Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,CA 21011 <br />