Laserfiche WebLink
APPLICATION <br /> Qi (For Non-Transferable, Revocable,'and Suspendable) $EPTAGE <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicata n is hereby made to carry on business in the jurisdictional area of.the Sa <br /> n Joaquin. goal Health District <br /> Address 1 !L 5 - <br /> Business <br /> Name (DBA) �(_� <br /> x Firm Partners.Owner Addresses� � nd Tele/hone Numbersr — Address <br /> ' - -- <br /> L Business Telephone No. Emergency Telephone No.. <br /> Contractor Licence No. Date <br /> _' <br /> ..�•� ,2 'Title�Xl�1 �1-I _ Date~ — <br /> c Applicants Name (Print) l��pZ� ---1 �- <br /> Please check Applicable Category (1-7)and Flll In the Re Ir13d Information ? <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1._ June 30, 19 - _ Disposal Sites.- —� <br /> Description(Make/Yr.,Color) CAL. License Renewal No.,. <br /> Serial No, CAL. License No. ( r <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. ❑ PERCOLATION TEST R.S. or R.C.E.NO. _ <br /> R.S. or R.C.E. Name — <br /> Test DateMme - <br /> Test Location —. -- - <br /> 4. K SANITATION PERMIT � — <br /> Job Address/Location <br /> Owner /%�. � �_ - Address_ -s--r:��--� E��`Nf <br /> ❑ LEACHING FIELD 11 SEEPAGE PIT-- PACKAG PLA T <br /> 1:1 SEPTIC TANK ❑ CESSPOOL 13 OTHER %G10q(34 q0 �'ti'�- <br /> 11 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW �I REPAIR <br /> - <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30. 19 _ - -- <br /> Type Construction _- , Disposal SiteNo. of Units Equipment Storage/Cleaning Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19, — Where Certified <br /> Operator Name — <br /> Plant Location <br /> _ No. Units Served _ — <br /> Plant Capacity <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/AmounVMO. — is IstlallnatemployaaYperSo� <br /> _ y tltatilttMpe>�einlatlGaotMevtaAttorlrniCattlis9>!tPtt�t - <br /> ltoareownero�acenurAt9cnrsturewrti11�91 sissaad.lshall <br /> in such roamer as to become subject to vrerxmarfs cornPelpatien laws of C4 10:Riay Stilt M 1M pNhlraeinc e W tfa worh t0►tr6i�ft this permit <br /> Cm�em w,s fihMO or aeD•eo►msotlaY wWMRuus ms's Ufe foilpvrlrq: <br /> employ p>q m subject to workman s compeAaaWft laws W C8UWftW' Aat the work <br /> h and n Joaquin Local Ill be done in Health District ccordance with San Joaquin County <br /> I hereby certify that I have prepared this applica <br /> ordinances, state laws, a rules and regul <br /> APPLICANT'S SIGNATURE - <br /> i <br /> �- FOR DEPARTMENT USE ONLY <br /> C1 PER SITF L3EACH ❑ January 1 R f7ece ved By Januafy 31 ❑ July 1 &Received By July 31 <br /> PER UNIT <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT. <br /> T BILLING �REMITTANCE 5 AMOUNT DUE CHECKED — <br /> nASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE - - <br /> LESS <br /> PRORA1ION <br /> PLUS <br /> PENALTY �• — � " <br /> UTHER <br /> OTHER <br /> Dale Rucelpl No. Permit No. Is5 Ance Date M3i190 DCliveretl <br /> Rr.celved by '1601 E.HAZELTON AVE.,P.O.Box 20o9 STOCKTON.CA 95701 — <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />