Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. tiebure Io algn IneNNNr�a+� • <br /> APPLICATION <br /> (For Non-Transterable,Revocable,and Suspendable) �9 SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT z <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) Al S i✓S �✓ Address Aye <br /> z Owner_ Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. GS–3 7 Emergency Telephone No. <br /> a Business Telephone No. <br /> a ` <br /> Contractor Licence No. /S3571? 3 <br /> Applicants Name (Print) F Title ' Date—6" 7- <br /> Please check Applicable Category (1-7)and Fill In the Required Information J <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. GAL. Licc�se Renewal No, <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 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. J� SANITATION PERMIT <br /> Job Address/Location L <br /> net — 64- C Address <br /> 4 I SEPTIC,TANK 11 CESSPOOL LEACHING FIELD A SEEPAGE PIT ❑ PACKAGE PLANT �y , <br /> . PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER Y <br /> O. <br /> 5. 1:1 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 /> M <br /> Operator Name Where Certified <br /> Plant Location <br /> r 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 /> AT-, ok ��-�8 z <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 regulations of an Joaquin 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 &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 /> C O� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 5LI S3 8 d <br /> Received byate Receipt No Permit No. Issuance ate Maile e ivered <br /> APPLICANT—RETURN/t}t1, OPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />