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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ` LIQUID WASTE <br /> Application is ereby made to carry on b siness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA AddressIF <br /> I a OwnerAf Address �� m. _ <br /> 2 Firm Partners,Addresses and Telephone Numbers <br /> a. Business Telephone No. . Emergency Telephone No. <br /> Contractor Licence No. <br /> r L Applicants Name (Print.) Title ez.,2-M- Date -1-:2 VZ5 ®' <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0 <br /> For July 1, June 30,19 Disposal Sites <br /> I Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. %`� <br /> Equipment Parking Address y j� <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 a <br /> No. of Vehicles Stored - r zn- <br /> No. of Chemical Toilets Stored -- <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time i <br /> 4. ❑ SANITATION PERMIT _ > r� <br /> Job Address/Location ! GtJ i DRIP Aog`,, /11 eef. <br /> O�w'10 �' a Address Sg_,o- a <br /> ( �1 SEPTIC TANK ❑'CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE-PLANT, <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NE 1 ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 31J 19 a <br /> Type Construction Disposal Site _ _.__' *. K <br /> a No. of Units _ —Equipment_Storage/Cleaning Location(s) '~= <br /> 6. ❑ PACKAGE TREATMENT PLANT For July,.1,-June 30, 19 <br /> Operator Name - Where'Certitied <br /> Plant Location - - <br /> f. _, - _ _ .. - - ti•- ,are - <br /> No. Units Served ^' ' <br /> Plant Capacity ^` ; <br /> 7.� 1-1LAUNDRYFor July 1,=Jprfe-30 19 <br /> -y—r-0-05" <br /> SIZE: ❑ Less Than 1:bOgLSq. Ft.;" "❑ More Than-] 00_Pq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Av { <br /> 1 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,.and-rules and r ulatio s,of-the-San-Joaquin'-Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FORDEPARTMENT S ONLY <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ~✓°'- 'ElEACH ❑"January 1 &-Received By January 31 ElJuly 1 &Received By July 31, <br /> -A *k'- _ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ : AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> 202z A <br /> FEE ; t •►` 'b• <br /> LESS <br /> PRORATION <br /> PLUS <br /> 4 <br /> ,k PENALTY <br /> OTHER <br /> N.- <br /> Alia— <br /> OTHER <br /> .OTHER <br /> 14,.. <br /> f - Received by- Date - - ReceipfNo-'`+ ' Permit•No. Is uance D 1e Mailed Delivered - <br /> ,APPLICANT—RETURN ALL COPIES TO:,g -ENVIRONMENTAL HEALTH-P"ERMITISERVICES� 1601 E.HAZELTON_AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />