Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendatile) $EPTAGE'_ <br /> ;�. ENVIRONMENTAL HEALTH PERMIT rIN <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name(DBA) Address <br /> z Owner Address - -- <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business,Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br />'I <br /> Description(Make/Yr., Color) <br /> Serial No. 4 ---,-=CAL_License No. v- CAL. License Renewal No. <br /> Capacity f Gal.,1�eighTs &Measures'No. <br /> Equipment- rki g Address <br /> 2.1,❑ PUMPER YARD <br /> ForJuly 1, / June 36, 19 <br /> No. of Vehicles Stored i <br /> No. of Chemical Toilets Stored- <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. f <br /> Test Location -" Test Date/Time ' <br /> r 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT f;n <br /> ❑ PERMANENT ❑ TEMPORARY 11 1EW-' C] REPAIR ❑ OTHER <br /> 'i 5.''❑'`CHEMICAL TOILETS Fbrl 61y 1�7-`Jtune 30"19 <br /> li Type Construction- 'Disposal Site <br /> No, of Units f'—. 'Equipment Storage/Cleaning Locatio_n,(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT- For July 1,--June 30, 19 <br /> Operator Name " '`K4 - Where Certified <br /> Plant Location <br /> Plant Capacity i =. "" No,Unifs Served 4c,e. .' ^.. <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. <br /> '7 r <br /> I hereby certify that I have.pyepa.red;this,apQiicatian'and that the work will be done in accordance with San-Joaquin County _ <br /> ordinances, state laws,trta rbies":and•regulations of the,S216 Joaquin Local Health"District. <br /> s' <br /> APPLICANT=S SIGNATURE X <br /> FOR-,DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER`SITE.. e❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Ju;y 31 <br /> ti's �� BILLING REMITTANCE $ REMIT <br /> BASE. a. ' EXPLANATION AMOUNT DUE CHECKED <br /> t _• - DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ..- .'9 <br /> PENALTY <br /> OTHER { <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.HAZELTON AVE.,P•O.Box 2009 STOCKTON,CA 95201 <br /> L <br />