Laserfiche WebLink
r. - <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> 1 (For Non-Transferable, Revocable,and Suspendable) S n r <br /> ENVIRONMENTAL HEALTH PERMIT r' ^'``= <br /> LIQUID WASTE <br /> Applications hereby ma a to carry on usiness in the jurisdictional area of the Sa ,Joaq In Local Health D' irict <br /> HBusiness Nam (DBA)0?r' 2 'rA � p_ rG�r. � Address- -1-',7 '�` ------ <br /> a Owner I • I Address <br /> ------- <br /> Firm Partners,Addresses and Telephone Numbers --.__ <br /> CL <br /> Business Telephone No. — � / .`� -_ Emergency Telephone No. --- - - <br /> Contractor Licence No <br /> ' - ---- r <br /> L Applicants Name (Print)_—.teaS (' �' Title /'�` 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.Licznse Renewal No. _ <br /> Capacity _. Gal.,Weights&Measures No. -- <br /> Equipment Parking Address - - <br /> �. 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 C <br /> No.of Vehicles Stored _ <br /> No.of Chemical Toilets Stored 1 <br /> S <br /> 3. ❑ PERCOLATION TEST 6 <br /> R.S.or R.C.E.Name- R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/L catign :2- "142 — e <br /> Owner /r/ /- ,�.�17e�LG`� Address <br /> F< < <br /> iSEPTIC TANK ❑ CESSPOOL LEAD C711NG FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> t PERMANENT ❑ TEMPORARY E] 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 /> Where Certified <br /> Operator Name — <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 /> ❑ rY CLEANING.,Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and tie_work will be done'in accordance with San Joaquin County <br /> ordinances,state laws,and rules po regulations of the'S in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPA�;TMENT USE ONLY <br /> PER UNIT ,t D.PER SITE 11EX'GH ❑ January 1&Received By January 31 El July 1&Received By July 31 <br /> Fee IS DMe:❑ ANNUALLY ❑ <br /> REMIT <br /> • BASE_ -APLANATION BILLING R�MITTAyCE. $ AMOUNT DUE CHECKED <br /> DATE 1'' DATE, - REMITTED AMOUNT <br /> FEE mz — <br /> a <br /> PRORATION - <br /> PLUS - P <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date Mailed D ere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCK, ON,CAN 5201 <br />