Laserfiche WebLink
� lF ' Applications Will Be Processed When Submitted Properly Completed. Be SureTosign 1ne„NNr�.¢•..••• <br /> _ APPLIC.ATiON <br /> � �� SEPTAGE <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> A <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> F Business Name (DBA) <br /> Address y <br /> z Owner <br /> a <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. � 9 J <br /> Contractor Licence No. Title Date <br /> L Applicants Name (Print) w 1- <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) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address s <br /> 2. ❑ PUMPER YARD h <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.G.E.No. i <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. P(SANITATION PERMIT <br /> Job Address/Location , <br /> Owner Address _ <br /> ❑. CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAG.E PLANT <br /> SEPTIC TANK REPAIR 34 OTHER Ada 04,/ U , <br /> { PERMANENT ❑ TEMPORARY NEW <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction - , <br /> 046sal Site <br /> No. of Units Equipment Storage/Cleaning L6cation(s) <br /> g, ❑ PACKAGE TREATMENTPLANT For July 1, -June'30, 19 Where Certified. <br /> Operator Name <br /> Plant Location ` <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 s r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLE,tNiNG Chemicals Used/Amount/MO,s• a - <br /> al?r'kg39�74t'1@i'Z`Yt��4�w',T�1a cna+2 ;^� 14 aao _ a,� N :ice f t:•,�•�..;:.. gn.,....i. r..r-� <br /> fit�t7C1fiflailfli:;:�,,t '+3R''' .� 3i� e,.. .- . <br /> ..�..VMleofthe:t0rkfarwhichthispermifisissilsd,Ishallnotemployanype�� <br /> - <br /> j11U)J 01 the wYOri(for 1':til: this pefir It i5 isSL''•d,16!1311. <br /> w1. hereby certify that'l have prepared this application and that the work will be-done.in accordance with San Joaquin County t . <br /> iin Local Health District. <br /> ordinances, state laws, and rules and regulati s o e San Joaqu <br /> 'APPLICANT'S SIGNATURE t <br /> FOR DEPARTMENT USE'ONLY t <br /> anuary 31 ❑ July 1 8 Received July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH .y ❑ January 1 &Received By JREMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATkON DATE DATE REMITTED AMOUNT <br /> FEE <br /> J L <br /> LESS <br /> PRORATION <br /> PLUS C <br /> PENALTY <br /> OTHER t, ; <br /> 1�r <br /> > OTHER - Q <br /> Receipt No. _ Permit No.a Issua ce Date Mailed Delivered <br /> w ) Received by 1Jat1.e r <br /> .APPLICANT—RETURN ALL COPIES TO: ENYIAONMENTAL HEALTH PERMIT/SF <br /> RY10ES v 1691E.HAZE TON A .O.Boa 2099 STOGKTON.CA 95201 <br /> ¢ r t <br />