Laserfiche WebLink
1 .aYYiy,'iuii� iq i„ Ot! riu�ub f rlen Juunmteu eruperly L.0 n1 P IeleU. be :,ure 4 l'gil I he AppiiGaLtul I. <br /> APPLICATION t } <br /> — ---- (For Non-Transferable, Revocable, and Suspendable) <br /> ZEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatiart�is hreby I a to ca- on business in the urisdictional area of the San Joaquin al Hea D lct <br /> Business ame ( Bf�) _ �'"�� _ Address f��,�-�/��I f�/ <br /> D^ner � Address ,1 S <br />-h In Partners, Addresses and Telephone_Numbers <br /> { G <br /> 3usiness Telephone No. _ 1 - G (O -—_ Emergency Telephone No. <br /> ttractor Licence No. ; <br /> 4 flicants Name (Print) Title r� Date <br /> --ase check Applicable Category (1-7) and fill in the Require Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> =July 1, June 30, 19 Disposal Sites <br /> cription(Make/Yr., Color) -- <br /> 3eriai No. CAL, License No. _ CAL. License Renewal No._ _ <br /> -acity Gal.,Weights & Measures No. <br /> ipment Harking Address <br /> 2�-❑ PUMPER YARD �C <br /> =or July 1, June 30, 19 <br /> `r.of Vehicles Stored y <br /> 1.—of Chemical Toilets Stored <br /> 1. F-1 PERCOLATION TEST <br /> 3r or R.C.E. Name R.S. or R.C.E. No. <br /> f t Location Test Date/Time <br /> II <br /> I. SANITATION PERMIT �. � �(.,�LL �"'�r <br /> Addres Loca ion - --- <br /> 1 -- <br /> D1er _.' 'Y Address G� <br /> 1--SEPTIC TANK ❑ CESSPOOL �r-LEACHtNG FIELD PErSEEPAGE PIT ❑ PACKAGE PLANT a <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> ir'❑ CHEMICAL_TOILETS For July 1, -June 30, 19 <br /> h <br /> rr a Construction Disposal Site �� <br /> ,4o. of Units Equipment Storage/Cleaning Location(s) <br /> ,',] PACKAGE TREATMENT PLANT For July 1, -June 30. 19 Q <br /> �} :rator Name Where Certified <br /> 'ia tit Location <br /> plant Capacity No. Units Served <br /> ?Jr 'D LAUNDRY For July 1, -June 30, 19 <br /> 3�. E: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I <br /> I hereby certify that I h ed this application and that the work will be done in accordance with San Joaquin County , <br /> ordinances, state laws, andq regulations oft San Joa uin Local Health District. <br /> j APPLICANT'S SIGNATURE X _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE i EXPLANATION OUNT DUE CHECKED <br /> REMITTED <br /> DATE DATE AMOUNT <br /> / i ✓ - <br /> FEE <br /> LESS l/ <br /> kkk a PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER C -- <br /> iii` 1 OTHER <br /> 33 <br /> Received by Dale Receipt Na. Permil No. ISSuancE Data Mailed eliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERIJI{TlSERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOC TON,CA 55201 <br />