Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl Icatiop,is ereby made to carry on Psiness in the jurisdictional area of the San Joaquin Local Health District T <br /> OF Business N A) Address '3 ' <br /> aOwner Address <br /> Firm Partners, Addresses and Tele hon umbers I <br /> a. Business Telephone No. Emergency Telephone No. i <br /> Contractor Licence No. <br /> L Applicants Name (Print) X TitleO Date <br /> Please check Applicable Category(1-7)and Fill in the Required information r. ,i,- <br /> 0 SK„:n SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ^. F -:3 L;u . X513 <br /> 5 <br /> For July 1, June 30, 19 Disposal Sites <br /> .4, r <br /> Description(Make/Yr., Color) y r' <br /> Serial No. CAL: License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address 4,1 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> 4 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored r <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 `�y ► ' \`� <br /> Owner 'V MG 1C.\, C •5e. Address ' 1U43 M 'IcV <br /> 12LSEPTiC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER �, a <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r $ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 V <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. 4 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. / U <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 d regulations of the San J aquin Loc I Health District. <br /> APPLICANT'S SIGNATURE X Ci ARE.(`iCPS 'T'I^ inAl <br /> 253 So. n?Ya x Si�t:!±��,., 088. 95205 <br /> p^. 53-3239 C�, r:cfor`s Lig.-25717.7, T <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 y <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE PATE REMITTED <br /> AMOUNT <br /> FEE �5 j -* L4,S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY` <br /> OTHER <br /> OTHER <br /> �l 151t7 11 �' <br /> Received by Vate Receipt No. Permit No anc Date Mailed elivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 1TON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />