Laserfiche WebLink
Applications Witt Be Processed When Subn1itled Properly Completed. Be Sure To Sign The Applicaffoh. <br /> A?PLICATION <br /> (For Non-Translemijic, RevOCa-;JIe,-and-*,uspendable) <br /> ENVIRONMENTAL HEALTH, PERMIT 3 <br /> 11OUID WASTE <br /> Ap.pLicahon is j*f4or76mj9;4,Aj�p or-,jurisdictional arca of the San Joaquin Loca;Health District <br /> -_---- _.—___ _ — -4fddress <br /> Busin <br /> 'o� ZZA <br /> Owner Address <br /> L) F"rrn Partners, Addresses and Tel Nurn - <br /> - <br /> Emergency Telephone No. <br /> a, Business Telephone No. <br /> v-j <br /> Contractor Licence No. <br /> jftppil­�­ Date <br /> --- <br /> Applicants Name (Print) <br /> pleasL, check Applicable Category (i-7) and rill in tile Required In1QTM1f1lan <br /> 1, 13 Pumpr--R VEHICLE PERMIT REGIST RATIO14 (FOR EACH VEHICLE) <br /> For July l.. 1. "1 Silos <br /> June 30, 19 Disposal <br /> Description(Make/Yr,, Color) <br /> Cf,..! ,_icpnt-,e No. CAL, License Reneyvaj_No.___. <br /> Serial No. L <br /> assures No. <br /> Capacity Gal.,W69�11" <br /> tquiprnent Parking Address <br /> 2, E] PUMPER YARD <br /> J U ly 1,_ June 30. 19 <br /> _ of Vehicles Stored <br /> N,5 of Chemical Toilf;ts Stored <br /> PERCOLATION 'TEST R.S. or R.C.E. No. <br /> S. or R.C.E. Name <br /> I fst.Location Test <br /> 4x SANITATION PERMIT <br /> job Address/Location <br /> Addross <br /> J,4vner <br /> r " ACKAGE: PLANT <br /> LEACHING FIELD SIFT�� <br /> Aa, Sr-PTIC TANK CES 00 7A I <br /> V70 1) <br /> PERMANENT El TEMPORAFlY riEPAIR OTHEn <br /> CHEMICAL TOILETS For .tiny 1, - June 30, 19 <br /> TvPe"'Cobstrdctions <br /> ant Storage/Q'leariltiq Location($) <br /> N.J. of Units Equipment <br /> 6 G PXCKAGE TREATMENT PLANT For July 1. - Junc 30, 19 <br /> Whero Certified Ciperator Name <br /> pirint Location, <br /> Plant-Capacity No. Units Served <br /> 7. LAUNDRY For July 1, - June 30, 19 <br /> 0 <br /> SgZE: 0 Less Than 1,000 Sq..Ft;, Mol-L" than 1,000 Sq. Ft,t <br /> 0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this ipplication and that the work will be done. }rl accordance with Sail Joaquin County <br /> ordinances, state laws, and rules a regu#atiuns of the .San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> Foll DEPARTMENT USE ONLY <br /> Fee IS Otle: 0 ANNUALLY ©PER IjN1TEACH JFwimly I 11riceivori 6y Ianuwy 31 jufy 8 Recclived 13Y July 31 <br /> BILLING FirNvTTANCE S AMOUNT DUE GlIECKED <br /> CASE E*ILANATION KIATI.: IDATI' I Rt-MITTrD AMOUNT <br /> FEE <br /> PENALTY <br /> OTHER <br /> 3. OTHER. <br /> Issunn a Dat <br /> Received by A/P <br /> APPLICANT—RETURN ALL COPIES TO: F..-4VIFIONMENTAL HkALTk PERMIT/SERVICES ,601 E.IIAZELTON+',"E_P.O.8ox 21109 S70C,,70N.CA 95201 <br />