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) Q <br /> ENVIRONMENTAL HEALTH PERMIT SEP�AGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA) Lf Ful—C-9-p— 'A>ddress <br /> z Owner—A , 2. Address Z'6 �a_ <br /> a 'i <br /> J Firm Partners, Addresses and Telephone Numbers > ; <br /> aBusiness Telephone No. �/ - Emergency Telephone No. ` <br /> Contractor Licence No. �s <br /> Applicants Name (Print) > zejLe-`FR Title ��>� '� Date a; p" <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 i <br /> Description(Make/Yr., Color). <br /> Serial No. CAL. License No. CAS_. Licznse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. Cl PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles StoredNo. of Chemical Toilets Stored <br /> 3. ❑t PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner ' Addresses' <br /> ❑ SEPTIC TANK 1:1 C'E'SSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type.Construction Disposal Site <br /> t <br /> No, of Units_ Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE tREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> �. <br /> Plant Location L` <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,19 ri <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More.Than 1,000 Sq:Ft. .� <br /> ❑ <br /> DRY CLEANING, Chemicals Used/Amount/Mo`. _ <br /> I hereby certify that) have prepared this application and that the work will be done in accordance with San-Joaquin County <br /> ordinances, state lawsfand rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X, x <br /> i <br /> � r y <br /> i <br /> FOR DEPARTMENT USE ONLY' <br /> Fee IS Due: ❑.ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January;l WReceived By January 31 f:❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING - REMITTANCE,.,-—, $ y AMOUNT DUE CHECKED <br /> DATE, , DATE REMITTED AMOUNT <br /> FEE <br /> i <br /> i <br /> LESS <br /> PRORATION - II <br /> PLUS s S <br /> PENALTY ' <br /> OTHER <br /> ~OTHER _ y <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />