Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> • APPLICATION <br /> Kt� <4-6 0S (For Non-Transferable,Revocable, and Suspendable) <br /> � `"� ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) r /9 Al T 1,o^,t/ N Address 4C06',7 Q G.0 0, /*/*6 <br /> z Owner 4 e f, ft a^"j Address <br /> Firm Partners, Addresses and Telephone Numbers �'��'`/ <br /> a. Business Telephone No. .5 z 3-`/z Emergency Telephone No. 1 <br /> Contractor Licence No. <br /> Applicants Name (Print) ,AP e. Title CO/l��Y��f/C�' Date <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. License Renewal No. <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. o. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMITQ <br /> Job Address/Location S40oe)a W'4 /W I-o r 11*71 y zxw <br /> Owner '44 13o r71 4 b o Address s;09'Ar C z <br /> M-SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT to <br /> O—PERMANENT ❑ TEMPORARY ❑ NEW JVREPAIR OTHER <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 Q <br /> Operator Name Where Certified <br /> Plant Location N <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 preparN this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules re ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE LA, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ��6(�� <br /> Received by Date Receipt No. Permit o. Issuance Date Mailed De ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STA CA 95201> <br /> v <br />