Laserfiche WebLink
ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.„ <br /> F APPLICATION <br /> (For Non-Transferable, Revocable, and Suspe!hdable) SEPI`AC f <br /> Y ENVIRONMENTAL HEALTH PERMIT <br /> a LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the an J quin Local Health District <br /> N Business Name (DSA) 09.8JQ/ f 1S1y SQ444��C- Address 9T a©/ <br /> aOwner - Address <br /> J Firm Partners, Addresses and Telephone Numbers p� <br /> IL <br /> Business Telephone No._- ������ 7 Emergency Telephone No. �11 <br /> Contractor Licence No. do <br /> L Applicants Name (Print) Titl Date e—3r0 <br /> Please check Applicable Category (1-7)an 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. L CAL. License Renewal No. - <br /> Capacity _. _ ' Gal., Weights &,Measures'No. <br /> Equipment Parking Address f. F <br /> 2. ❑ PUMPER YARD F <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored f <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. NameR.S. or R.C.E. No. U� <br /> Testi Loo ate <br /> tion r Test D /Time - <br /> 4. L'f SANITATION PERMIT <br /> JobAddr�e�ssl1/Location `�Z- 98'�S <br /> Owner�l� .Address€ �tiPV? <br /> ❑ SEPTIC TANK ❑ CESSPOOL iK LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> D-VERMANENT ❑ TEMPORARY ❑ NEW 2 REPAIR ❑'OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site y <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 A � No. Units Served i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 � - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1 <br /> r <br /> I hereby certify that I_Jozay prepared this application that rk w91*be done in accordance with San Joaquin County <br /> ordinances, state la les and r ations of an aqui L Health District. <br /> APPLICANT'S SIGNATURE <br /> k \ <br /> S <br /> t <br /> FOR DEPARTMENT USE ONLY v <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 1 ❑ PER SITE ❑ EACHs° ❑ January 1 &Received By January 31 ❑ Ju_!y 1-&Received By July 31 <br /> I BILLING 'REMITTANCE $ <br /> `Y RE <br /> MIT <br /> BASE EXPLANATION DATE= DATE REMITTED AMOUNT DUB CHECKED <br /> it � '�' AMOUNT <br /> FEE <br /> LESS t 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> Hrez- OTHER <br /> OTHER <br /> Received by Date Receipt No. Perm if No.` Issua ce Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ._1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />