Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE } <br /> Application is hereby made tot arty on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) 4J .r/S77?�-�lC-77o Address />' <br /> aOwner Address <br /> a Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 3 9;71 Emergency Telephone No. <br /> Contractor Licence No. -S S <br /> LApplicants Name (Print) F" lr10e Title Date _z_C� <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. L#cense Renewal No. <br /> Capacity 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 R.S. or R.C.E. No. <br /> Test Location Test Date/Time�v 4 <br /> 4. . SANITATION PERMIT � <br /> Job Address/Location l-'L3 to 6 ,o,e��os.a 2� ; � G,Groy✓ __ <br /> Owner J i�r�f � Address— 4. 1� <br /> IkSEPTIC TANK ❑ CESSPOOL (LEACHING FIELD A(SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY X NEW ❑ REPAIR ,❑BOTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �pJ <br /> Type Construction I i Disposal Site W <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 +. <br /> Operator Name 0 Where Certified I <br /> Plant Location <br /> Plant Capacity �( No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19'( <br /> : <br /> SIZE: 13L <br /> Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Name ownefarttEenmdapont'8gsfdntatutoeerfttietthofollewlng:"Icertifythatinthe performance oftheworkforwhlehfhisPerm ItilloEllod,113h;tll ®(®tflpltfyiRy)�I)fstlrl <br /> lh suth mariner as to becbti d s€il ittt to*0tktfl AI1's cbmP01181100n laws of California." <br /> Contractor's ttL466 pr A A-CahtfaeAiIC eignatum cortiftes the following: "I certify that in the performance of the work for which thi§p&rmit Il}14§994,1 0411 <br /> I)hiploy pifi6f g subJ@tit if)wofkniatl'i t:ortittadsatlon laws of California:' <br /> 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 rules and regulations of the Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE D TE REMITTED AMOUNT <br /> FEE B_ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 27 ' <br /> OTHER <br /> OTHER 1 <br /> Received by Date , Receipt No. Permit No. ls4jance Datle Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -'ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 200 STOCKTON,CA 95201 <br />