Laserfiche WebLink
1 <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> A —IVV'3$11060 (For Non-Transferable, Revocable,and Suspendable) SEPI \C. [: <br /> f/ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District //�� <br /> N Business Name (DBA) BR4iimboCh a P(nzz 3Fm l `a <br /> Address 7 s il) lSt Lnd -, <br /> a Owner--Teri 1QZZal Address �C,LdYL(L <br /> L) Firm Partners, Addresses and Telephone Numbers 5 eve Vail►iirz sat,Az <br /> M <br /> Business Telephone No. 71 A 16 I E Emergency Telephone No. 5c>lvfn,L <br /> Contractor Licence No. _ <br /> L Applicants Name (Print)r ESS —U 7�J <br /> pZZA 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�ololYNI EDIT <br /> Capacity Gal., Weights t£ Measures No. <br /> RECEIVED <br /> Equipment Parking Address } <br /> 2. ❑ PUMPER YARD 1990 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored FNVIRQNMENT�l� ?"'^ <br /> No. of Chemical Toilets Stored PFRAAIIIISERVICES <br /> 3. JK PERCOLATION TEST <br /> R.S. or R.C.E. Name It '_1A?ZA Sag—L6 R.S. or R.C.E. No. iC001A to <br /> Test Location Test Date/Time <br /> 4. E] SANITATION PERMIT 1MCOV6V.. <br /> vee <br /> µ� <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 Disposal Site <br /> No. of Units _ ue" Equipment Storage/Cleaning Location(s) C <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 /> konwownerwiicensedegent•ssignature­t;ffesthe/olfowkw."Icertftyyt#wlnthe pe>iormenceofthe workforwhichthispermit isissuedlshall notemployany person <br /> in such manner as to become�ubiect to wor';,,,a.i s compensation laws of Caliiornia" <br /> Contractor's Airing or sub-coat.aaioq i;•,r rt r< foiforring: '1 certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons suUject to workman's,,ampt rIsdtnu,+d.va of�,atiwtnra" <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, an ules re ulaions <br /> ionsof the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �___'N <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />