Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />(For Non-Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br />EIQUID WASTE <br />Application is hereby made to carry on business in the Jurisdictional area of the San Joaquin Local Health District <br />Business Name (DBA) D. 4 . R.,e, IS s Address_l <br />Owner Address <br />-r-2, Firm Partners. Addresses and Telephone Numbers <br />Business Telephone No. -4464— 0407 Emergency Telephone No. 1 <br />Applicants Name (Print) Title -___&:g_nf_k_t_9_7Me—. Date __Jr.,- <br />d Contractor Licence No, S-41 3 4 <br />97 <br />Please check Applicable Category (14) and Fill in the Required Information <br />0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />Description (Make/Yr., Color) <br />z <br />For July 1, June 30, 19 Disposal Sites'çy d <br />Serial No. CAL. License No. CAL. Renewal No. <br />Capacity Gal., Weights & Measures No.' <br />Equipment Parking Address _ <br />0 PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />.No. of Chemical Toilets Stored <br />3, 0 PERCOLATION TEST <br />R.S. or R.C.E. Name <br /> R.S. or R.C.E. No. <br />Test Location Test Date/Time <br />4. 2( SANITATION PERMIT <br />Job Address/Location 7 7 r:t 4 -She ..e. .1) . )fe E ot.1 CI,/ l2..11-014 P <br />Owner 141.5,F,„..._. 20%0 _ Address PO 13 ,1W 1.4 , Pde.givo. il dAi i 1 A <br />f'SEPTIC TANK 0 CESSPOOL orNr LEACHING FIELD 0 SEEPAGE PIT 0 PACKAGE PLANT <br />PERMANENT 0 TEMPORARY 0 NEW - IVREPAIR 0 OTHER <br />S. 0 CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction . Disposal Site <br />No. of Units .Equipment Storage/Cleaning Location(s) <br />0 PACKAGE TREATMENT PLANT For July 1, - June 30. 19 _ <br />Operator Name Where Certified <br />Plant Location <br />Plant Capacity No, Units Served <br />0 LAUNDRY For July 1, - June' 30, 19 <br />SIZE: 0 Less Than 1,000 Sq. Ft, 0 More Than 1,000 Sq. Ft <br />0 DRY CLEANING, Chemicals Used/Amount/Mo <br />I hereby certify that I have prepared this application and that the wtirkewill be done in accordance.with San Joaquin County <br />ordinances, state laws, and rules and reg ations of t Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />• <br />Fee Is Due: 0 ANNUALLY .' <br />FOR DEPARTMENT USE ONLY <br />0 PER UNIT 0 PER SITE .0 EACH ' 0 January 1 & Received By January 31 0 July I & Recetyed By July 31 <br />BASE EXPLANATION aiLLiNG <br />DATE <br />REMITTANCE <br />1 DATE <br />$ <br />REMITTED AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION .. af -1 / <br />PLUS <br />PENALTY " ... <br />OTHER '41 <br />OTHER — <br />• <br />• <br />2 7 T evi y 7 9- 7 il7 0/0 7; T 2/77 . , 0 <br />Receiv y D e Receipt No. . Permit No Issuance at Mailed <br />— ...... , • TN • T /I K. A IIIC Ns 11.2. °WM <br />P r <br />drrite ^hi 1 A OS21111