Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 'Y APPLICATION <br /> / mor Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati is he a made to rry og business in the jurisdictional area of the n ° uin L}cal Health Di trict <br /> k,r, B',siness�Name (DBA r /7 e //! Addres T ( U/1R00Ve <br /> L.wner Address__I Z 6 Q n' sa n R <br /> Firm Partners, Addresses andTelephone�T[elephone Numbers _ <br /> aBusiness Telephone No. 7 "73- Z0L1, Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) S 7 Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity 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. N PERCOLATION TFST <br /> R.S. or G Name 0 el- - l R.S.or .0 .No. <br /> 17 _3 1 <br /> Test Location / Test Date/Time <br /> 4. ❑ SANITATION PERMIT /:z,? tYL 'fi/�-GGyi <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-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 Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served 1 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. I �j <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work VIM be done 44 ordanc4" t6Wbaquin County <br /> ordinances, state laws. G / � , 1 <br /> APPLICANT'S SIGNATURE X 1_�L1 =6f L6 `�6�1 Title e6'/ Date !2 f3 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT_ <br /> FEE 77?(lYJ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - 3_1z- ?'I <br /> ��--2-- <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.Bos 2009 STOCKTON,CA 95201 <br />