Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> k APPLICATION <br /> ?; (For Non-Transferable,Revocable, and Suspendable) $EpTAGE <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> j1QUID WASTE <br /> Application is reby made to car on business in the juri ictional area of the Sp Joa uin Local Health Dist <br /> Business Name (DBA) <br /> Address <br /> 1,77 <br /> z Owner «� Address <br /> a <br /> S2 Firm Partners, Addresses and Telephone Numbers <br /> a ` Emergency Telephone No. <br /> Business Telephone No, <br /> Contractor Licence No. - �- <br /> L Applicants Name (Print) — Title <br /> Date .3 <br /> Please check Applicable Category (1-7) and Fill in the RequirLd Information <br /> 1`ElrP MPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites <br /> For-:July�1;,..� _-" rJune 30, P <br /> Description(Make/Yr.,Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Capacity ,r~'� Gal.,Weights &Measures No. <br /> k <br /> Equipment-Parking,Address <br /> 2. ❑ PUMPER`YARD1 } <br /> For July i, r 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 PERMIT <br /> #[F Job Address/Location VA 0r7 2-- �' J <br /> 6 S <br /> Owner <br /> Address:- <br /> 11 <br /> ddress❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELDrSE 'AGE PIT ❑ PACKAGE PLANT Q` <br /> lk A <br /> 13 PERMANENT 11 TEMPORARY ❑ NEW x} EPAIR- <br /> 11 OTHER <br /> 5. ElCHEMICAL TOILETS For July 1, -June 30, 19ry <br /> Type Construction Disposal Site a <br /> No. of Units Equipment Storage/Cleaning Location(s)_--4 �- - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Fol <br /> 1 Operator Name There Certified — <br /> plant Location 1! <br /> No. Units Served <br /> Plant Capacity <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 /> l - ' - t <br /> certify that I have prepared il;,,aplcation and that?the work will be done in accordance with San Joaquin County <br /> ! hereby ce y P -�, <br /> ordinances, state laws, and rules and r la s of the Sa q. 'n Locate I4 :District. <br /> k -,qtr <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONL <br /> Fee Is Due: ❑-ANNUALLY ❑ PER UNIT I PER SITE ❑ EACH ❑ Ja ry 1 &Received By January 31 July 1 &Receiv July 31 <br /> REMIT <br /> F BILLING REM ANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> iOTHER <br /> OTHER <br /> Date - Receipt No. Permit No. Is ance to Mailed Deli eyed <br /> �. Received by - ; <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.RAZELTON AVE.,P.O.Boz 2049 ST CKTON,CA 95201 <br />