Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �t <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> _ _,4„`� ENVIRONMENTAL HEALTH PERMIT SPTAGE 1 # <br /> ( � (Q7 /v• E �� (�!� LIQUID WASTE C)L( -� / <br /> VA-,j <br /> Application i hereby made to carry on business in the risdictional area of the S��Joa�Local Health Di trict <br /> ' ''-J'- Address GFS t F <br /> �Business Nam DBA) � � I <br /> z Owner Address <br /> C c 47 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. � S�Q Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title Date �� -16 -7 c <br /> Please check Applicable Category (1-7) and Fill in the Required Information 4 <br /> 1. ❑ 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. Liccnse 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 i <br /> No. of Chemical Toilets Stored k <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 5 <br /> Test Location Test Date/Time <br /> 4. 1$ SANITATION PER.' j I <br /> Job Address/Location =11 �� t , ` _ 4 <br /> Ow r C Address Q 4 p� 1✓-trt�— �� <br /> 'L' SEPTIC TANK ❑ CESSPOOL � -ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 2 NEW ❑ REPAIR ❑ OTHER (� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 7S <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 <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> t <br /> ordinances, state laws, and rules d regulatio oft n•Joaquin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> rye FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT e1 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED I <br /> ,J DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> i <br /> .PLUS <br /> i <br /> PENALTY <br /> OTHER _ <br /> i <br /> li <br /> OTHER <br /> -79 <br /> I j <br /> 1- Received by Date - Receipt No. Permit No. Issuance Date Mailed Delivere _ <br />[ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 5201- <br />