Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> '} <br /> APPLICATION <br /> Z� <br /> 97(D� (For Non-Transterabfe, Revocable,and Susp able} S f TAGE <br /> «c ENVIRONMENTAL HEALTH PER T � <br /> LIQUID WASTE 1 1 <br /> Atiplication is herebyade to carry on business in the jurisdictional area of the San loaq Lin ocal Health District <br /> siness Name (DBA)_- 'Z,! Address ��✓ .r'1' CJS <br /> Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> E. Business Telephone No, _ Emergency Telephone No, <br /> Contractor Licence No. 'ts � <br /> a Applicants Name (Print) Title ___.d 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 Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST k <br /> R.S.or R.C.E.Name R.S. or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. A SANITATION PERMIT {� <br /> Job Address/Location C <br /> Owner <:I. a-re Address :T-z7,26:: 6.4, <br /> 19 SEPTIC TANK ❑ CESSPOOL iP LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. El-CHEMICAL TOILETS For July 1,-=June 30,-19 _ <br /> e Construction <br /> _ P Disposal Site <br /> of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified t <br /> Plant Location � �•- - t <br /> Plant Capacity - No.-Units Served <br /> ?. ❑ 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 /> Nomeanrner or licensed agent's Sjorm1ure rsrtiffes the following:"I rert4jy th in in fhe perform a nct+of the'Work for wAph`thi5 permit IS lS�utKj l Shall not er+ipMy any persOtt <br /> in such manner as to becomesutlleet to workmart's ccnlpensatEcn'aws s!Caiifore:a." :, r - <br /> CoatracWeS hiring or sw atting siJ4natr,re certlffes the foltovA `1 cerci that in the erformarice of itt.4rk for which this permit Is i&- e t shall <br /> empfay persons subject to workman's compensation laws of California." P T <br /> I hereby certify that I have prepared this application and that the workrwill begone In accordance with San doaquin,Courity <br /> ordinances,state laws,and rules an re ul Ions of the San Joaquin Local Health Distjict. r <br /> APPLICANT'S SIGNATUREX �!+ ��" t <br /> FOR DEPARTMENT LISE ONLX„ <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH'ti, ❑ January 1 S Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> J BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> • �^�.� DATE DAJE REMITTED _ AMOUNT <br /> FEE <br /> f <br /> LESS 1v a <br /> PRORATION <br /> PLUS �r _ <br /> PENALTY , <br /> .OTHER <br /> OTHER — \ <br /> Recervac by Date Receipt No. Permit No. Iss ance Date Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO. 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1681 E-HAZELTON AVE.,P-O.Box 2009 STOCKTON,CA 95201 <br /> r <br />