Laserfiche WebLink
Applications Will Be Prt. T Sed When Submitted Properly Completed. Be S To Sign Th cath.� <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) / <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Health Dist <br /> ,F Business Name (DBA) <_/ /�L /— / C"' _ Address <br /> Owner._ ..'_r-_"� �' . / rlr:' Address :c %•< <br /> u Firm Partners. Addresses and Telephone Numbers <br /> 5. Business Telephone No fit' Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) _ %/A7 ! ;i f✓1,ii'� Title c' � �(c C�� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <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. 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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name .._ /- / R.S. or R.C.E. No. L, c' 1_ /i <br /> Test Location �l �� f %1'�i- �% �_ Test Date/Time /A /, & L <br /> 4. ❑ SANITATION PERMIT <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 <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 <br /> ordinances, state laws. <br /> ,!' / !'9 ; f °G, i;�1 Date C <br /> APPLICANT'S SIGNATURE X Title :�7 -- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TOS ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 9Ss.41,-- <br />