Laserfiche WebLink
.Appllcatlons will tie Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) C <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE C <br /> LIQUID WASTE E <br /> Appli ) is heI m e to carry buss es rn the w ' dlctional area of the S n oaquin cal alth District J <br /> Business (DBA) _ �IC,bi �t?'S l�ac^r �ue ' n. � t AYe <br /> _, .'9R�r/� Address O v 1-fOnJ <br /> a Owner. 1/1'1 Address- S"4 MC <br /> o Firm Partners, Addresses andel�P 3 6cne Nurn - <br /> Business Telephone No. .G 'r Emergency Telephone No. <br /> Contractor Licence No. y 3�/ <br /> L Applicants Name (Print) Title <br /> Date <br /> 'Please check Applicable Categori!(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30. 19A Disposal Sites <br /> Description(Make/Yr., Color) ISerial No. CAL. License No. CAL, Liccnse Renewal No. <br /> Capacity Gel.,Weights&Measures No. <br /> Equipment Parking Address .I " <br /> 2. ❑ PUMPER YARD B <br /> For July 1, June 30, 19 I <br /> No. of Vehicles Stored �. <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i[ <br /> R.S. or R.C.E. Name 1' R.S.or R.C.E.No. <br /> Test Location Test Date/Time ,. <br /> t. 11SANITATION PERMIT O+ O S C m <br /> ob Address/Location c Ave /-(/- �;�1r1,P G <br /> Owner�[s�s H 10 l RATA k A Address �O r3 oY //G /CR (iq✓h� C q Q <br /> IrSEPTIC TANK CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ElPACKAGE PLANT <br /> D PERMANENT C3 TEMPORARY C3 NEW ®REPAIR ❑ O HER <br /> 5. 13 CHEMICAL TOILETS For my 1,-June 30, 19 <br /> Type Construction Disposal_ I <br /> Site_ <br /> k.o. of Units �4 Equipment Storage/Cleaning Location(s) <br /> 13PACKAGE TREATMENT PLANT For July i,-June 30, 19 <br /> Operator Name II _ Where Certified <br /> tdant Location <br /> lant Capacity No. Units.Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> ZE: ❑ Less Than 1,000 Sq. Ft', ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> s <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, s and reguJ@tions oflha San Joaauln Local Health District. _ <br /> ,PPLICANT'S SIGNATURE X II LA �1 " <br /> ti <br /> 9 FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY Q PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Recelve8 By January 31 ❑ July/K Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNTDUE CHECKED <br /> + AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r+1 <br /> OTHER <br /> N <br /> fl.uance <br /> OTHER <br /> ee <br /> Relvee y Dat <br /> Date ;Malld; DelivereC ( ✓• <br /> APPLICANT=RETURN ALL COPIES O: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.am 2888 STOCKTON,CA 95201 <br />