Laserfiche WebLink
M <59Z O/3O <br /> APPLICATION <br /> -- --•- .- _ ..._... _* ` Z � <br /> For Non-Transferable. Revocable, and Suspendabltlr)/ SEPTA("' <br /> ENVIRONMENTAL HEALTH PERMIT 5!<I LY <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) JtW IL,L)r,&(,W fpita-71A _ Address. 37�ZZ W EL&A ST. LIM Com. '75Z�L <br /> Owner__—AMPJ&,`L__PjbZ ---- Address <br /> u Firm Partners, Addresses and Telephone Numbers 3�DQ `LOCO w• /� <br /> Business Telephone No. seo 0-66 10 Emergency Telephone No. C29 _64t <br /> Contractor Licence No. <br /> Applicants Name (Print) -_-TERKY p)&ZZA Title 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. 0Y PERCOLATION TEST - - ---R.S.or CSE Name -MMY P16ZT-A_ R.S. or,11EDNo. <br /> Test Location -20 M. - Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location _ <br /> Owner _ Address— <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> s. ❑ 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 a <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 /> 4 <br /> 1 hereby certify that I have prepar Is application and tha�t a work will be done in accordance with San Joaquin County �t v <br /> ordinances, state laws, d regulations the San, oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X / '� c <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 /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMIT <br /> AMOUNT <br /> FEELESS <br /> ��•v 2•(1� TvS�— U <br /> PRORATION <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received bf Date Receipt No. Permit No - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES M. ENVIRONMENTAL HEALTH PERMIT;SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />