Laserfiche WebLink
ApplicationsWill 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 <br /> St=PTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin LocIf Health District <br /> ur Business Name (DBA) , �, �. <br /> i Owner " t Address f` iY <br /> Ja Address <br /> Firm Partners, Addresses andTelephone Numbers - .e <br /> a. Business Telephone No. / <br /> a Contractor Licence No. ,� j Emergency Telephone No. <br /> .. L Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information Title _ f'cr t Date 1- 7 <br /> t 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - <br /> Description(Make/Yr., Calor) ; <br />' Serial No. CAL. License No. <br /> I Capacity CAL. License Renewal No. <br /> 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 <br /> R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4• ❑ SANITATION'PERMIT , <br /> Job Address/Location ,� ,• J e v I <br /> Owner le_ -7- taJ Address CZ U x <br /> SEPTIC TAN ❑:CESSPOOL LEACHING FIELD ❑ ' � V� <br /> SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - <br /> Disposal Site <br /> D <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Plant Locationt t. ( Where Certified <br /> Plant Capacity No. Units Served <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 /> t <br /> I 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,(nd rules and r gulatians of the San Joaq in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 4 <br /> 1 1 V? <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNITS ❑ PER SITE -❑ EACH ❑ January 1 &Received B Januar 31 ? <br /> -= y Y El July 1 &Received BY July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT + <br /> LESS € <br /> PRORATION <br /> PLUS t r <br /> PENALTY # <br /> k <br /> OTHER ` ! <br /> OTHER <br /> Received by ate eceii No. er I l <br /> P Permit No. Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered <br /> Y501 E.HAZELTON AYE„P.O.Box 2089STOCKTON,CA 95201 <br />