Laserfiche WebLink
r <br /> Applications Will Be Processed When Submitted Properly Completed. Be SureToSign <br /> APPLICATION I <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG� <br /> ;- LIQUID WASTE <br /> Applicationl7 <br /> is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health i�stric�t. <br /> rBusiness Name (DBA) Address <br /> z Owner ��SE'' Address /!/33 /V_ /`�A L _ 0 S 4'8 <br /> d <br /> r Firm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No. - Emergency Telephone No. ��`�' 36,9 2069 <br /> 'Contractor Licence No. C-- z8_9¢ <br /> Applicants Name (Print) �� �E 1 ��'�� Title ���� R. 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 y <br /> I l <br /> Description(Make/Yr., Color) <br /> r <br /> GAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> a <br /> 1 Capacity Gal.,Weights &Measures No. <br /> k Equipment Parking Address , <br /> rr v <br /> 2. ❑ PUMPER YARD G <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> ;k/DSot 4 P76- <br /> A �M _)3. �PERCOLATION TESTyuArzr��R.S. or R.C.E. Name DvAAI - ifsear RNo. <br /> t 835 �_ �AIN1�P /z17 MA - est Date/Time 3-8¢ /3C-6i 08 � Alt_ <br /> F Test Location <br /> r 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> 11 SEPTIC TANK ❑ CESSPOOL C3LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT _F <br /> ❑ PERMANENT C] TEMPORARY ❑ NEW 11 REPAIR 11 OTHER <br /> ° h <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I T <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> i. No. Units Served <br /> F Plant Capacity <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 /> 1 <br /> Hantoo�erartieanaeda�ant"ss', `'1e{n°=�v3�^�"�r•^'`if" �!he perfermanCeofthcwork forvdf=ichthis permit isissued,lshall not employ atryperson <br /> In such marcor as to become 5:3r#�v ie 1r : t <br /> CoontMCtor'sM,3C13►ti�,1 fS���+r��'I�as!s-�a -.4rc¢�s; F:, _..s.,._. .-....4W•;;. `�c�:l 1; thet i,,ilic pnitrrrm�.nce of the worts for which this permit is issued,I shall <br /> employ persm Sit j"a W wafi'kr aZ;li-�rMl�ilv�leie.t"W Lav5 3I cdi:"11 oia." <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 nd regulations oft San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 -,FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1.&Received By January 31 ❑ July 1 &Received By Juiy 31 . <br /> HEMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE- DATE REMITTED AMOUNT <br /> FEE ' 0 D� <br /> LESS <br /> PRORATION <br /> ( PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> Received by - Date Receipt Na. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,GA 95201 <br />