Laserfiche WebLink
Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> • * APPLICATION <br /> and Sus ndable) SEP"AGE <br /> \\ (For Non-TransteratNe, Revocable, Pe <br /> �ry ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is hereby made to Car on business in the jurisdictional area of the San Joaqul calH ItDistrict <br /> y Business Name (DBA) Address _,i /�� �/-- • — <br /> Owner Add ass - <br /> }} ----- <br /> Y Firm Partners Addresses a Teyhon a- —� <br /> a Business 'e ephone No S(� Y _ Emergency T lephone No. --- — <br /> Contractor Licence No.__ --- ---- -_ -- <br /> ��/�— Date ---— <br /> a Appl cants Name (Pant) -- -- -- --- Title <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 /> CAL. License- No- __ CAL.License Renewd No. <br /> Sepal No. _ _ _ _ <br /> Capacity _ __ - (311.,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 Chemicai Toi�ets StoreC - - <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S or R.C.E. Name -- -- — <br /> Test Date.,-Time __-- - -- -- <br /> Test Location —_-- - _ __--- __ _ - <br /> 4. ' NITATION PERMIT <br /> Job Addres Location <br /> Addr -- <br /> Owner S� <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE IT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30. 19 <br /> Disposal Site Dispo <br /> Type Construction — <br /> -- <br /> No of Urlts —_ —_ Equipment StorageiC lean i ng Location(s) - <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 _ -___ <br /> Where CertttieC <br /> Operator Name _ -- -- -- t <br /> Plant Location _ - No. Units Served <br /> Plant Capacity - —-- <br /> .-- <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/AmounVMO. —— — -- <br /> I <br /> I r)ereby certty the I na e area this ap IC ion and that the work will be done in accordance with San Joaquin County <br /> ordinances,state I a d r I and r ulati ns f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 1z — <br /> r-- <br /> FOR DEPARTMENT USE ONLY <br /> I b ROCawad By January 31 C] July 1 b Received By JWy 3t <br /> Fee it 1766e:❑ ANNUALLY C] PER UNIT OPER SITE ❑ EACH ❑ January REMIT <br /> BILLING REMITTANCE $ AM LINT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT _ <br /> FEE hfS <br /> LESS - <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER ' <br /> 7 <br /> Recsrved M <br /> Date Ratelp NNo P m7t No ssuance date MA wive <br /> APPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.tw 1006 STOC$rrON,CA <br />