Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transfer e, Revocable, and Suspendable) <br /> ENVIR .ENTAL HEALTH PERMIT SEFT.AGE <br /> LIQUID WASTE <br /> Application i hereby ma to carry on business in the jurisdictional area of the San Joaquin Local Health District # <br /> 4S SQ'm Business Name (DBA) O <br /> z Owner � Address �'O 4 RZ 7 <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. G1 Emergency Telephone No. <br /> Contractor Licence No. 34, <br /> L Applicants'Name('Name(Print)) ".C Title �/' Date <br /> Please check-Applieable:.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 /> Description(Make/Yr., Color) i <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. _ 1 ' <br /> Equipment Parking Address V--T Nx. <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 r4t�. � <br /> r <br /> R.S. or R.C.E. Name fS" C-1k r m R.S.or R.C.E. No. <br /> Test Location �- ^ ; Y Test Date/Time ! 4J <br /> 4. SANITATION PERMIT015F ry �.�# 4E (! *• "a, t <br /> Job Address/Locations _/y <br /> Owner /P�r 1p/;�V/TS-� Address�/ �'t Cas JIX , �, , <br /> 11 SEPTIC TANK ❑, CESSPOOL LEACHING FIELD C3E PIT ❑ PACKAGE PLANTS t ' <br /> d 1 if <br /> PERMANENT 11 TEMPORARY` 11 NEW ..� REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,,w-June-30,-19 ) <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Whele Certified <br /> Plant Location _ f <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 N <br /> I hereby certify that I have prepared this application and that the work ill done I cord San Joaquin County a <br /> ordinances, `state law n r es and regulatio s of the an Joaq in Loc th Distrtt. <br />` <br /> t- i . I <br /> APPLICANT'S SIGNATURE X <br /> t FOR DE NT USE ONLY �. <br /> ---.r_ •�.- 1 - <br /> Fee Is Due. ❑ ANNUALLY ❑PER UNIT �❑PER SITC— 0 EACH- ❑January 1 &Received By January 31�� ❑ July 1 Received BySJuly 31 <br /> REMIT <br /> 1 i BILLING REMITTANCE $T AMOUNT DUE CHECKED <br /> BASE EXPLA�ATION _ <br /> � DATE DATE REMITTED AMOUNT <br /> i FEE S J, <br /> k LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY t <br /> r - <br /> 1 OTHER <br /> OTHER <br />{F' t d T <br /> F77 q <br />' Received by pate - � Receipt No. -'- �- "" Permit No:' `v'-'"`Issuance Date Mailed–Delivered "^ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMI7L$ERVICES 1601 E:HA2HLTON AVE.,P.O.Box.2009.,0_STOGKTON,CA 5201" . <br /> —... <br /> JAI <br />