Laserfiche WebLink
�/ ApplicationsWill 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 /> LIQUID WASTE <br /> Application is ereby made to carr on business in the juri dictional area of the San Joa uin Local Health D' trict <br /> rn Business Name ( A) ' ,� f�- <br /> iOwner Addresses 7E 7 <br /> a Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. 0 S <br /> t Emergency Telephone No. <br /> j Contractor Licence No. z <br /> �Applicants Name (Print} Titleidg_'L Date r 4 <br /> Please check Applicable Category (1-7)and Fill in the Required Information O <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July 1, _ _ June 30, 19ti <br /> - Disposal5ites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. Oar, <br /> CAL. Liccnse Renewal No. <br /> Capacity —Gal.,-Weights & Measures <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 Lotion Test Date/Time <br /> 4. LJ SANITATION PERMIT `S t a <br /> Job Address/Location ✓�'Jr O _ � o._ <br /> Owner Address s <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD I_,' PAGE PIT El PACKAGE PLANT <br /> El PERMANENT - ❑ TEMPORARY DINEW L REPAIR ❑ OTHIwR <br /> 5. ❑ CHEMICAL TOILETS For July 1;�June 30, 19 <br /> ` ' ' 'R A% 1 1 <br /> ruction <br /> Type ConstDisposal Site f i <br /> No. of Units t Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT.PLANT For July 1, -June 30, 19 1 I °r <br /> Operator Name �' 1 <br /> 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 /> t <br /> � <br /> I hereby certify that I have prepared this application and that the work will be done in accordana� th San Joaquin County <br /> ordinances, state laws, and rules a regulations of the Jo uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> YJ ., <br /> FOR DEPARTMENT USE ONLY - <br /> Fee IS Due: 11ANNUALLY 11PER UNIT ElPER SITE 13EACH [Ell January a ived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING RE TTANC $ REMIT <br /> BASE EXPLANATION <br /> DATE ATE REMITTED AMOUNT DUE CHECKERAMOUNT <br /> FEE zs��_r , <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ;�� — .- I <br /> 6 0 4"_jReceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />