Laserfiche WebLink
Applications Will Be Prot—sed When Submitted Properly Completed. Be SL_ +'o Sign The Application. <br /> APPLICATION ,��y'//�S <br /> / � <br /> (For Non-Transferable, Revocable, and Suspendable) // ^ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i's hereby m de to c ry on business in the jurisdictional area of the San Joaquin Local Health Dis3 rict <br /> F Business Name (DBA) 1 �1��v,lvi.4z24 Address —c b, L U o/ <br /> a Owner 7 • X1,47-2 d Address f�.of G <br /> J'Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. < Emergency Telephone No._:�7 _t�'�1b <br /> -J Contractor Licence No. _ <br /> Applicants Name (Print) T of �i�a Z 2� Title �Cr� « Date 1604--A-1 <br /> Please check 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 <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 (� <br /> R.S. or R.C.E. Name I (-t' A 22/.�- R4-er R.C.E. No. �7 Cv C: <br /> Test Location 2 4 w d Test Date/Time -- <br /> 4. ❑ SANITATION PERMIT <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 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 /> I hereby certify that I have prepare ' application that a work will be done in accordance with San Joaquin County <br /> ordinances, state laws <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUAL ❑ PER UNIT ❑ PER SITE ElEACH 1:1January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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 />