Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION Il <br /> (For Nan-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Address—A-7 <br /> a Owner J `C,.7 TZ R' Address CLIME. <br /> J Firm Partners, Addresses and Tele hone Numrbers <br /> ILBusiness Telephone No. —A 1 5 - 7 8{' 1'Z-1� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print)� t! tom,4 U�'�Ris.-�s I Title f - i Date�-V ��� <br /> Please check Applicable Category (1-7) and Fill in the Required Information r t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) # <br /> For July 1, June 30, 19 Disposal Sites , <br /> Description(Make/Y�., Color) # ' <br /> Serial No. I CAL. License No. CAL. Licc7se Ren6wal No. 1 <br /> Capacity Gal., Weights &Measures No. = , <br /> Equipment Parkin'lA%ddress C—) <br /> g � � I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 r <br /> No, of Vehicles Stored a <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location ` Test Date/Time <br /> 4. ❑ SANITATION PEf3. i �,•„� ) F l <br /> Job Address/Location ` ► F�-.r _ <br /> ❑ SEPTIC TANK ❑y CESSPOOL ❑ LEACHING FIELD C1SEEPAGE Ply ❑•PACKAGE PLANT <br /> 11RO <br /> PERMANENT ❑'TEMERARY NEW IO-REPAIR .OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,.19 n <br /> t <br /> Type Construction_ Disposal Site r <br /> No. of Units EquipmentISttoorage/Cleaning Location(s)fi _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,-T9� : �.• <br /> Operator Name I +s'. r f Where Certified <br /> Plant Location r -71 <br /> Plant Capacity ) _ - - =No<,Units=Serted <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 iiit <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,, ❑ More Than 1,000 Sq. Ft. " <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> a <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, d rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> - f <br /> FOR DEPARTMENT USE ONLY l <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH, ❑ January 1 &Received By January 31 ❑ July-1 &R_eceived By July 31 <br /> BILLING REMITTANCE $ REMIT i3 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED i. 'E <br /> AMOUNT <br /> 1 <br /> FEE <br /> LESS <br /> PRORATION R <br /> PLUS <br /> ?d[ <br /> PENALTY i 1- <br /> OTHER <br /> i <br /> OTHER i <br /> - s � <br /> Received by Date Receipt No. Permit No. - Issuance D e ailed Delivere i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON .,P.O.Box 2009 STOCKTON,CA 95201 - ! <br />