Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Surf goiVn Aofigation l 11� � t <br /> APPLICATION. 6 9 <br /> Non-Transferable, Revocable, and Susperl JOAQUIN LOCALSEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT HEALTH DISTRICT D <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Lwl Hneaallltth District <br /> q Business Name (DBA) L20/7 \nS �___i9ss'cs�• Address /2 E 6 rF x' zTw c y <br /> i Owner f0;` ir,b -C�' Address r / Z` <br /> r <br /> Firm Partners, Addresses and Telephone Numbers <br /> i Business Telephone No. ?f'd'14.2Z Emergency Telephone No. <br /> Contractor Licence No. 9,2— <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and FIII In the Required Information' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, _ June 30, 19 ' Disposal Sites <br /> Description(MakeNr.,Color) I I 1 <br /> Serial No. 'CAL. License No. CAL. License Renewal No. NID <br /> Capacity _ Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD • - c <br /> For July 1, _ June 30, 19 <br /> No. of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location . Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location�t * /_6 <br /> owner Doel 3oSr— Address / <br /> PIL SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 1 <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER Q•• <br /> 5. ❑ CHEMICAL TOILETS. For July 1,-June 30, 19 - CID <br /> Type Construction 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.pt. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> if <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 rul s and regulations of the Sa J quin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> y <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING '-REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DAT REMITTED AMOUNT <br /> �' <br /> FEE \ , <br /> LESS ITXJ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �?c/, N2-7l�q /s 6 a a Iv�, 4 G. <br /> Received by Date f Receipt No. Perms No. Issue ce Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />