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) i <br /> Z ENVIRONMENTAL HEALTH PERMIT SEPTAGE _1� <br /> LIQUID WASTE S <br /> t Application is hereby made to carry on business in the jurisdiction. I area of the San Joaquin Local Health District s <br /> y Business Name (DBA) Ei O/Y !r- seA, Address P'.0, 4oX <br /> a Owner A e e Address O PtTa GA• q�3S�/ <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> a. 0 Telephone No. -sem 3' y2/ Emergency Telephone No. X00 3 <br /> Contractor Licence No. <br /> L Applicants Name (Print) ee Z4 ire Thati Title co/yn-^, y- Date Y' <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. Licc^se Renewal No. 411 <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 <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 1? SANITATION PERMIT <br /> Job Address/Location I"oT yQ,1/ Cf6CsTiYvT' ST, JPae.Y CLVG ?YAC]/ <br /> Owner )V,0>164d Te9AXT Address ep'gF W N ATr ST, CleVl 9 fd CA. <br /> 0 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 9 NEW ❑ REPAIR ® OTHER /L7'ey 13ec� <br /> i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity_ No. Units Served <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 /> 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, and rul and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 1>7 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �/ AMOUNT <br /> FEE �.? <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> IVl -7 1 77 779 - moi No. -21 1A <br /> Received by Date Receipt o. Permit Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,CA. 5201 <br />