Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.- <br /> APPLICATION <br /> "F ,. (For Non-Transferabie, Revocable, and Suspendable) SEEPAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Loc Health Dis`tri t <br /> y Business Name (DBA) �I`A T-'AS I&Ii- Address( <br /> i Owner t Address - <br /> 4 <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. .5� 23� __ Emergency Telephpne Nv. Z3`� 2_SC?9 <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title • A 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 /> Description(Make/Yr., Color) ° <br /> Serial No. CAL, License No. CAL. License 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 y <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 r C- <br /> Owner �' �" .� Addressl1 - <br /> &KSEPTIC TANK ❑ CESSPOOL 21LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 21PERMANENT ❑ TEMPORARY ErNEW ❑ 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) k <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 I <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 prepared this ap 'cation ago that the will done in accordance with San Joaquin County <br /> ordinances, state laws, and rule egul o s of an in cal H Ith District. <br /> APPLICANT'S SIGNATURE X - - <br /> 1 a <br /> OR DEP RTMENT 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 /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED - <br /> AMOUNT <br /> FEE 45 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -k <br /> ( 311-5 __7 9-`1, � <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 />