Laserfiche WebLink
�^y ^F'Yi...c.uv..a •,u. .,c . iv.caac.. ,r..v.i .��..,ia...c,.. , ..,F.�..y v.a,.F..�w... .... .....� ... ...moo � r.r�,....-..,... <br /> I l+t APPLICATION <br /> S r Non-Transferable. Revocable, and Suspendai <br /> ENVIRONMENTAL. HEALTH PERMIT S r G'' <br /> LIQUID WASTE <br /> F Application is h ereby,made to.carry on business in the jurisdictional area of the San oaqu€ Local Healtin DI #rict <br /> y Business Name (D8A) Address <br /> ~ Owner � a L «y= _ c� Address <br /> F <br /> .4141. 1'4Z� <br /> Firm Partners, Addresses nd Telephone Numbers <br /> 1-Business Telephone No. 4_;__ OC. Emergency Telephone No. .1 <br /> Contractor Licence No. - — <br />€ `Applicants Name (Print) = -.6-- z LJ�. Title Pre Date - - <br /> 'Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> iFjFor July 1, June 30, 19 Disposal Sites <br /> F; <br /> YDescription (Make/Yr., Color) <br /> I Serial No. CAL. License No. CAL. Licc-se Renewat No. <br /> Capacity Gal., Weights & Measures No. ` <br /> lEquipment Parking Address <br /> 4 J2. ❑ PUMPER YARD <br /> -'+For July 1, June 30, 19 <br /> r No. of Vehicles Stored <br /> Z�--+�No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> 0R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test location Test Date/Time <br /> 4. 3 SANITATION PERMIT <br /> ,fob Address/` ation $' y <br /> FOwner d Address <br /> EI SEPTIC TANKP]❑ CESSPOOL ❑ LEACHING FIELD S EPAGE PIT ❑ PA•CKAG PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW td REPAIR ❑ OTHER C>1 <br /> �O <br /> 5. El CHEMICAL TOILETS For July 1, -June 30, 19 <br /> F <br /> Type Construction Disposal Site C� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> -F;1� <br /> 6. 1:1 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> FI7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZEi ❑ 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 <br /> Fordinances, state laws, and rulZ�__4-z <br /> d regulations of he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> FILL BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUN �J <br /> FEE . <br /> R LESS <br /> PRORATION <br /> PLUS I - I 1'y •.. i L/ <br /> PENALTY i <br /> - OTHER I I of <br /> fff i <br /> OTHER l <br /> Recewed'oy Daie Receipt No Permit No Issu nce Daie Mailed Delivered <br /> APPLICANT---R£TURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 95201 <br />