Laserfiche WebLink
,.P �n�rwlr9 "Oil ElPPrut!es6od WII&I gulfmtllod Propwly 06010491ba. 0@ fluro To 61 0--n 'SII@ Appilt~allott, <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r Application is reb�yade t ca on�i siness in the ju.i dictionai area of the S n Jos uin Local Health I]IStr' <br /> �6uslnes3 Name (Q )_ - c. ��,_� f 3y., <br /> Owner o_ Dr �' Address._ i �� � <br /> Address -4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. <br /> Contractor Licence No, 2 —���- -- Emergency Telephone No. <br /> a <br /> L Appiicants Name (Print)_ r -- ----- <br /> --- Title Date_..`�-?�-Z - <br /> Please check Applicable Category <br /> (1-7) and Fill In the Require Informallon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 J <br /> Description(Make/Yr.. Color) <br /> w Disposal Sites w_ � - - <br /> Serial No. -�-- CAL. License No. - <br /> Capacity - ----_4 CAL. License Renewal No. Y�-�Y <br /> 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 <br /> Test cation R.S. or R.C.E. No. <br /> 4. SANITATION PERMIT Test Date/Time <br /> Job Address/Location )n v�---.1 <br /> Owner <br /> PTIC TA ❑ Address 0 <br /> BEACHING FIELQ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW , <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 El ❑ OTHER <br /> Type Construction Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Locations _— <br /> t3• ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ( �4 �� <br /> Operator Name — <br /> Plant Location -- ---~- - Where Certified _ <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 1-�9 Y -' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <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 taws, and rules ed regulations oftheS n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XZza& <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due; ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> ❑ EACH 11 January 1 8 Received By January 31 El July 1 &Received By July 31 <br /> BASE EXPLANATION BILUNG REMITTANCE REMIT <br /> —� DATEDATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS �r 1 �`ks <br /> PRORATION <br /> PLUS _ <br /> PENALTY — ---- <br /> OTHER <br /> OTHER <br /> Received 6Y Date Receipt No. —p---�-- — — ��1. <br /> I <br /> Permit No. Issue ce D Msi3ed <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMITISERVICES Oolivvred'�- <br /> - 1661 E.HAZELTON AVE.,P.O.Bore 2009 STOCKTON.CA 95201 <br />