Laserfiche WebLink
Applications Will Be assed When Submitted Properly Completed. BI •e To Sign The Application. <br /> APPLICATION <br /> 2_2_0 /' (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DPA) _ _ A dress <br /> a Owner ���� �� — - - Address l S7 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. _.___ _ _ _ __._— Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) „l/t.�/Q�11 C -S� _ _ Title /�/ ��`��� 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 i£ Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD -_---- — - - - -- ----_For July 1,____ June 30, 19 <br /> No. of Vehicles Stored - <br /> No of Chemical Toilets Stored <br /> 3. PERCOLATION TEST _ <br /> R.S.er R.C.E. Name R,.S.or R.C.E. No. <br /> Test Locations _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location --- - - -- - ---- - - - - - -- ---- -------------- --- - - <br /> Owner --- Address --- - - ------- - --- - -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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 <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 /> 13 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> � <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./� ,� <br /> APPLICANT'S SIGNATURE Xr�! �d`��' - Title% ,&-_/Z Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 8 Received By July 31 <br /> —T— REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE - / OO Q/- s – --- CPt� <br /> LESS <br /> PRORATION O <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �( <br /> &eived by bate Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT–RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 1009 STOCKTON.CA 95201 <br />