Laserfiche WebLink
Applications Will Be Proces then Submitted Properly Completed. Be Sure 1� )gn The Application. <br /> APPLICATION � <br /> /(For Non-Transterable, 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 Local Health District <br /> siness_Name (DBA) —_-. Address=. <br /> Address-Z2-1S--7-,V-��,f_"h <br /> m Partners, Addresses and Telephone Numbers <br /> siness Telephone No. —.3.34-=-L ✓ --- ---- Emergency Telephone No. <br /> ntractor Licence No. A , _— -- -- — -- W <br /> plicants Name (Print) �� �T A-?"""°_ —_ - - -- _— Title <br /> _ Date <br /> :ase check Applicable Category (1-7) and Fill in the Required Information <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> r July 1,- June 30, 19 Disposal Sites _--- — --- <br /> !scription(Make/Yr., Gator)_ — <br /> 1 rial No. CAL. License No. ,.�_.� -�_._ -�.CAL. license Renewal No. <br /> Epacity_ Gal-Weights & Measures No. <br /> E luipmenl Parking AddressEl PUMPER PUMPER YAR© <br /> )r July 1, June 30, 19 _ <br /> �. of Vehicles Stored -- -- _-- - <br /> �. of Chemical Toilets Stored <br /> fid PERCOLATION TEST ( �-�- <br /> S.or R.C.E. Name C&�1__�� � /-- R.S.or .C.E No. <br /> ( ,st Location Date/Time— — <br /> f ❑ SANITATION PERMIT <br /> >b Address/Location- -. �___ r ---- ► <br /> wrier RAWR <br /> — _ Address Y----- <br /> E I SEPTIC TANK ❑ CESSPOOL. ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ) PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR © OTHER <br /> © CHEMICAL TOILETS For July 1, - June 30, 19 <br /> ype Construction Disposal Site ---- <br /> lo.of Units Equipment Storage/Cleaning Location(s) - <br /> . ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> _ —Where Certified <br /> Iperalor Name <br /> dant Location — _-- <br /> 'iant Capacity --- --- —. No. Units Served _ <br /> ❑ LAUNDRY For July 1, -June 30, 19 L/ <br /> iIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. �- <br /> 1 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 /> APPLICANT'S SIGNATURE Title Date <br /> �2f/ 1� ���� <br /> 1 , <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT _❑ PER sit F ❑ EAC,H-- El January 1 d,Received By January 31 ❑ July 1 &ReceiveRdEB'y#Tuly 31 <br /> BASE EXPLANATION BILLING I REMITTANCE ITTANCE f AMOUNT DUE CHECKED <br /> DATE -_�1 — DATE REMITTED AMOUNT <br /> F'E£LESS <br /> PRO <br /> PRORATION .�. .,. <br /> PLUS — --.` - <br /> PENALTY <br /> �- OTHER ( -- <br /> OTHER <br /> o Reccio Permit Na_ <br /> Issuance Date Mailed Delivered <br /> t <br /> CART--RETURN ALLC IES TO: ENVIRDNIMEAITAL HEALTH PERNIITISERYICES <br /> 1001 E.HAZLLTON AVE-P.O.Box 2004 S7OCKTON,CA 95201 <br />