Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'gnd Suspendable) SEPTAG'c <br /> ENVIRONMENTAL HEALTH PERMIT MS-91--G0 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District• _ <br /> I Business Name (DBA) _ _ ._ Address__— <br /> Owner ma, elm. ATHIAa nAddress r13 2.7 _Sc4_ —_ <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No <br /> Contractor Licence No. _ - - <br /> 1 _ <- fVlt. E1JGlt.1IMP— Date Z"15--91 <br /> _Applicants Name (Print) bVAL'T1`� E,. t:.l)�'Tt5Title. - <br /> Please check Applicable Category (1.7)and Fill in the Required Information 9"(g <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (2 09) 3 G8--4159 <br /> For July 1, -- June 30:19 •. -Disposal Sites - <br /> Description(MakeNr.,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. A PERCOLATION TEST b� <br /> Fkfto. R.0 E. Name -V—= , CV-_-[175_ 111;*W.R.C.E. No. <br /> Test Location 17-32:7 SO. VAt4 AtS.EkA RIC:i, Test Date/Time aKCAVATjCMA e. i -iL"9-.9 I A <br /> 4. 1:1 SANITATION PERM ITI'�Ab{y,C/i t5 WAD Z-2A–q1 aM <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER ` <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t I <br /> Type Coristruction _� 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 /> F+oms ewnsrorNoensrd agsnt'asignature cortHies the following:1""ilIyy that in"performance of the Work for which this permit is issued,l shall not employ any person <br /> ki such manner as to become subject to warkthaiYg comyensatien laws M ralifarRia ' <br /> Cormat:tor's hiring or sub-contracting aigneturo eartifies the- h4lowing: 1 certify ttlat in tM perforinarh.e of the work for which this permit is issued,l shall <br /> employ persons subject to workman's compamation lams of GallforniC <br /> r ' <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and ules and regulationsn Joaquin Local Health District. _ <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dui:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t 8 Received By January 31 ❑ July 1 3 Received By Ju'y 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EI PLANATION AMOUNT DUE CHECKED <br /> DATE ``- DATEq RFMIITTED _ AMOUNT <br /> FEE /00- <br /> 4 'k rr� 1 , 1 2 1Z.Q-0 Z <br /> LESS <br /> PRORATION <br /> PLUS - - -- -_ <br /> PFNAt TY <br /> OTHER <br /> �. OTHER r - <br /> ReceivdU by Date Receipt No Permit No. Issuance Date Melted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sod 2009 STOCKTON,CA 96201 <br />