Laserfiche WebLink
AppllCet10r1S vent DC r•,Vcraaru MIC11 o.u......c.. . ..Lcn� v.....�,......... .... ....._ ._ .s.. ..._ - — 1 <br /> �� C2_ �: APPLICATION 4 V G I <br /> Tor Non-Transferable, Revocable, and SuspendabhT).01 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to�cccc,aaar on business in the jurisdictional area of the SaanJJoaquin Local Health District <br /> Business Name (DBA) Obt .&AP1�11T Address '32 �ELIA ST I IM' CA <br /> Owner plSZ•Y p�oZ ___- AAddress 'Al. F�• w� ST_ LJV1, —GA 15244 <br /> Firm Partners, Addresses and Teelle/phorleNumbers <br /> Business Telephone No. �- 6e <br /> Emergency Telephone No._ � - <br /> Contractor Licence No. - <br /> Applicants Name (Print) �T1=RR`s QiA ZZIA _. Title G.E. Date_ " Ile' <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 --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. Of PERCOLATION TEST /- <br /> R.S.or®Name P1RY PfoZZA __ R.S.or1rD No. <br /> Test Location VI/•�URT[ �__ �_—__ Test Date/Time <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 <br /> 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 /> -(�{5-�-- �� a--• pyo � '� ' �"-,��.��Q'��.`-<<< �z <br /> I hereby certify that I have prepared thi plication and that the worWwill be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru ul tions Of the n Joaquin-Local Health District. <br /> APPLICANT'S SIGNATURE X - -- <br /> 2TES 7 r-IGLES 'Z <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 /> BASE EXPLANATIONTBILLINIG REMITTANCE $ V AMOUNT DUE CHECKED <br /> E DATE REMITT AMOUNT <br /> FEE 6 . 24 L• A - <br /> LESS <br /> PRORATION -- <br /> PLUS <br /> PENALTY - - - <br /> OTHER <br /> OTHER <br /> _ <br /> Received by Dale Receipt No Permit No Issuance Date Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT'SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />