Laserfiche WebLink
Applications Will Be Processed When StslliUed Properly Completed. Be Sure To Sign The Application.. <br /> " tPiLI CATI O N <br /> (For Non-Transferable, Revocable, and Suspendable) $EP:TAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application jp hereby made to carry on business in the jurisdictional area of theAn Joaquin Local Health District _ <br /> m Business Name (DBA) J. e e5Z.Z44 4EXAddress Ino, <br /> z Own-or 'Address e <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone Na. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print)— —iry�Gs�Il� Title d Com/N � Date <br /> Please check Applicable Category(1=7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ForJuly 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. f� <br /> Equipment Parking Address <br /> _ 2. ❑ PUMPER YARD ,, . .�..:-.: <br /> For July.1, Julie 30, 19 _ <br /> No of Vehicles 816red, <br /> _ No. of Chemical.Toilets Store�tb <br /> 3. ❑ PERCOLATION,TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location jest Date/Time <br /> 4. 11 SANITATION PERMIT ' E �C.d7_ 3!g� <br /> Job Address/Location l d <br /> Own �a M4*�T Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD � ❑ SEEPAGE PIT ❑ PACKAGE <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW '❑ 'REPAIR ❑ OTHER t <br /> 5. (A'CHEMICAL TOILETS For July 1, -June 30, 19 v <br /> Type Constructfon _ 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 /> y ��M <br /> Plant Capacity No. Units,Served ` <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 Y <br /> SiZET ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. * "_ <br /> r <br /> I hereby certify that 1 have,prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rulesand r latiqDA. <br /> vf the San o quip Local Health District. = a <br /> APPLICANT'S SIGNATURE X - <br /> f <br /> FOR DEPARTMENT USE ONLY - <br /> ' Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE- ❑ EACH -- ❑ January''1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> `BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> —_FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTYHEIR <br /> OTHER" <br /> Receive y Date 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 2009 ST CA 95201 <br /> c•n7 <br />