Laserfiche WebLink
APPLICATION <br /> 1tr± (For Non-Transferable, Revocable, and Suspendable) <br /> -� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatiol�j f9reby ma o c ry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name A) <br /> --- ---- Address. <br /> ---- - --- <br /> Owner__- _ ___ -- - - - <br /> - Address <br /> -- - <br /> Firm Partners, Addresses and Telephone Numbers _ --- <br /> < Business Telephone No. - - ---- <br /> Emergency Telephone No. <br /> Contractor Licence No. - - - --- <br /> Applicants Name (Print) _ Title -. <br /> -- _------ 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 /> --------- --------- <br /> ascription(Make/Yr., <br /> Serial No. _ - CAL. License No. CAL. License Renewal No. <br /> Capacity <br /> 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. o Chemical Toilets Stored <br /> y: <br /> 3. PERCOLATION TEST ���/�- ------- -- ----- -- - --- <br /> I' R.S. or R.C.E. Nam / <br /> j _—_- R.S. or R.C.E. No. <br /> Test Location <br /> '��'-- -- ---------- Test Date/Time <br /> 4. ❑ SANITATION PERMIT - - - --- -- <br /> Job Address/Lucation <br /> Owner - ---- <br /> - _ Address <br /> ElSEPTIC TANK C3CESSPOOL ❑ LEACHING FIELD 1:1 _ <br /> 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 __- _ Equipment Storage/Cleaning Location(s) <br /> 6. 11PACKAGE TREATMENT PLANT For July 1, -June 30, 19_ <br /> Operator Name <br /> -- —.- <br /> Plant Location Where Certified - -- -------------- <br /> Plant Capacity _- No. Units Served <br /> 7. 0 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 /> 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 and r I tions of the San 4oaquin 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 6 Received 8 January 31 ❑ July I &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE3 REMIT <br /> A <br /> DATE GATE REMITTED MOUNT DUE CHECKED <br /> FEE •SD� ty.� -- --._-.----- - _. AMOUNT <br /> LESS -- - <br /> PRORATION <br /> PLUS --- - - - -- - - <br /> PENALTY - - -- —— - <br /> OTHER - -- -- --- <br /> ---- - - <br /> OTHER D .— — ------ -- - - <br /> �j <br /> Date <br /> Q - s <br /> Receipt No. Permit No Issuance DateMailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />