Laserfiche WebLink
Issuance bate Mailed Der'.:red <br />1601 E. HAZELTON AVE., P.O. Box 2009 ST CNTON, CA 95201 <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />(For Non-Transferable, 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 S n Joaquin Local Health District <br />Business Name (DBA) 0‘,4fr-be,447-ie Address ..3(,./c", t <br />Owner /'---e.,‘• Ar.ie Address <br />SEPTAGE <br />9 Firm Partners, Addresses and Telephone Numbers <br />— I <br />e 06 r V. . .1 3 7 t: Business Telephone No Emergency Telephone No a <br />j Contractor Licence No. Y,,c572 4:5-If •-. <br />1 Applicants Name (Print) ri,•...4,0 IC-tie - e 67.4. Title _i_._44/47-- it.- Date a <br />Please check Applicable Category (1-7) and Fill in the Required information 6— _ <br />F ' El 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 />0 PUMPER YARD <br />For July 1 June 30, 19 <br />No. of Vehicles Stored <br />.No. of Chemical Toilets Stored C, <br />0 PERCOLATION TEST <br />R.S. or R.C,E. Name R.S. or R.C.E. No. <br />Test Location Test Date/Time <br />. 0 SANITATION PERMIT <br />Job Address/Location - if.1 ,2 PIO/ ,,,VP ,5;- 4 <br />Own 'A:244 h. L:::. Address 5.4 •'--='. <br />0 CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction <br />0 PACKAGE TREATMENT PLANT For July 1. - June 30, 19 <br />No. of Units <br /> <br />--- Equipment Storage/Cleaning Location(s) <br />Disposal Site .., <br /> <br />SEPTIC TANK O.-CESSPOOL CI LEACHING FIELD 0 SEEPAGE PIT 0 PACKAGE PLANT <br />0 PERMANENT 0 :TEMPORARY El NEW El REPAIR • 0-OTHER <br />Operator Name ..' -.... Where Certified <br />Plant Location - _ <br />Plant Capacity No. Units Served - <br />0 LAUNDRY For July 1, - June 30, 19 <br />SIZE: 0 Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br />0 DRY CLEANING, Chemicals Used/Amount/MO <br />" <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, and rules a eglons o e San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X de. <br />FOR DEPARTMENT USE ONLY <br />›le0 1 <br />.> <br />EXPLANATION <br />Fee Is Due: El ANNUALLY CI PER UNI1 <br />BASE <br />Cit PER SITE 0 EActi <br />BILLING <br />DATE <br />0 January 1 & Received By January 31 <br />REMITTANCE <br />DATE REMITTED <br />o July 1 S. Received By jwy 31 <br />REMIT <br />AMOUNT DUE CHECKED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />111 ee, PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receipt No Permit No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEFIMIT/SERVICES