Laserfiche WebLink
.r.�....".... ..� . ... .... .....�....w . u..., .,uulnna.v r tuNa. .� �.u1„�.,..w. ..,. v.. .v ...�, .n.. ...........",. <br /> APPLICATION <br /> (I Ion-Transferable, Revocable, and Suspendable <br /> ENVIRONMENTAL HEALTH PERMIT r{C'^ <br /> LIQUID WASTE <br /> Application er y rrkpe to c ry n business in the' risdictional area of the San Joaquin Lo�cc �� alt Istria - �1 <br /> —usiness Name DBA) Address ��3 <br /> Owner__ Address <br /> irm Partners, Addresses and Telephone Numbers 7l <br /> _usiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> ^pplicants Name (Print) TitleLtL _ ”— Date <br /> lease check Applicable Category(1-7) and Fill in the Required Information <br /> 'T. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> escription(Make/Yr., Color) _— <br /> . aerial No. CAL. License No. _ CAL. Lice,se Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> quipment Parking Address - <br /> _. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Io. of Chemical Toilets Stored <br /> ❑ PERCOLATION TEST O <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> est Location Test Date/Time <br /> ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Iwner ` 42 Addres r_L L <br /> SEPTIC TANK ❑ CESSOOL EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORAP.Y ^NEW ❑ REPAIR ❑ OTHER <br /> S. CHEMICAL TOILETS For July 1,-June 30, 19 <br /> ype Construction Disposal Site <br /> -Mo. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> 1perator Name Where Certified <br /> _'lant Location <br /> Plant Capacity No. Units Served <br /> -. ❑ 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 /> 1 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, and ule nd egulati of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> 7 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ AMOUNT <br /> FEE CA <br /> LESS <br /> PRORATION /v – <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER --- --- ---- -- -- -- — — — -- -- r <br /> �e^olwed by Date Receipt No Permit f�O c^ c lus^Tcce Dul^"c o^ oaded^^n Bell^tired„ <br /> 11!`^r.IT—OCTIION 111 1 rnOIFG Tn� PNVIRrI NIJGNTAI HFAI TM UGn VIT Ic[n UI!`c< <br />