Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Non-Transferable, Revocable, and Suspendab <br /> ENVIRONMENTAL HEALTH PERMIT 9EPTAGE <br /> LIQUID WASTE <br /> p <br /> Applicatso,, hereby r6Ade to carry on usm ss the jurisdictional area of the Sa Joaqui Local Hearth Distri t <br /> „Business a (D8A) N,� sem— � ' /Address �d a� � -�7 <br /> i Owner_ C_- � —_ _ Add s�s,_. _J,.�(�lo[� o_, L21 ' <br /> Firm Partners. Addresses and Telephone Numbers — +✓C_!G Sss r:�£ y _'-3 <br /> 5. Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> a Applicants Name (Print) _ r ck- S f Title Date i!�< <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 R Measures No. — <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> r <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. V SANITATION PERMIT <br /> Job Address/Location a W5-D e. Zf/ <br /> ` <br /> Owner —�rJit�t St 4,4b rho„c L4 Address .5 A--J'— - <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 10 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW OREPAIR ❑ 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 preph isapplicatipp and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru a - regulations t Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Cir <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE i EXPLANATION I DATE DATE REMITTED AMOUNT DUE ' CHECKED <br /> AMOUNT <br /> FEE— <br /> LESS <br /> I <br /> PRORATION I I E <br /> PLUS - <br /> PENALTY <br /> OTHER I i <br /> OT14ER j <br /> r�a Rereived by Date Rece-pl No. Pprmt No Issuance Date Mailetl eli <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �� 1601 E.HA,�ELTON.AVE.,P.O.Box 2009 STOCKT?>^95201 _ <br />