Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />'111.1010"--- LI 1.1 0 (For Non-Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT SE PTAGE <br />LIQUID WASTE <br />r <br />Application is herippy made t9;:cr on business in the jurisdictional area of the S J a9Liin Lotrie tri t 0 Business Name DI3A) VO/4.0.4- 1- z Owner 4 Address <br /> Address 41 6....--4 <br />Firm Partners, Addresses and Tele hone Numbers <br />le. Business Telephone No. ce <br /> <br />Emergency Telephone No. <br />7_ Applicants Name (Print)—anY Rd <br />ifir/ / <br />Title Date <br />:I Contractor Licence No. <br />Please check Applicable Category (1-7) and FIN in the Required Information <br />1. 0 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. <br />Capacity Gal., Weights & Measures No <br />Equipment Parking Address <br /> <br />CAL. Licznse Renewal No. <br /> <br />0 PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br /> <br />No. of Chemical Toilets Stored <br />0 PERCOLATION TEST <br />R.S. or R.C.E. Name R.S. or R.C.E. No. <br />Test Location <br />0 SANITATION PERMIT <br />Job Address/Location 7 96 eddr..-7t-ty <br />Owner 1 42-ak NA•-e-b J26 Address <br />0 SEPTIC TANK 0 CESSPOOL 0 LEACHING FIELD 0 SEEPAGE PIT 0 PACKAGE PLANT <br />CI PERMANENT 0 TEMPORARY 0 NEW <br />0 'CHEMICAL TOILETS For July 1, - June 30, 19 <br />REPAIR 0 OTHER <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 <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 work will be done in accordance with San Joaquin County <br />ordinances, state laws, d and reg ions of the S Joaquin Local Health District. <br />APPLICANTS SIGNATURE <br />FOR DEPARTMENT USE ONLY <br />Fee is Due: 0 ANNUALLY 0 PER UNIT 0 PER SITE 0 EACH <br />BASE EXPLANATION BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE S A/ • C5Cd <br />LESS PRORATION <br />/';gi r PLUS <br />PENALTY 2 <br />OTHER <br />OTHER <br />I. <br />Permit No. <br />'iLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 4/4,4 <br /> Test Date/Time <br />Where Certified <br /> —7 — lyed by Date Receipt No. Issuance Date Mailed Delivered