Laserfiche WebLink
rte' <br /> Applications Will Be Processed-When Submitted Properly Completed. Be Sure To Sign The Application. � r <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE UZ <br /> ' ENVIRONMENTAL HEALTH PERMIT �S <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District ^" <br /> r Business Name (DBA) ddress <br /> z Owner Address <br /> Y Firm Partners, Addresses and Telep one Numbers <br /> ya Busindss Telephone No. �-- 3 C2 9 Emergency Telephone No. <br /> Contractor Licence No. > s <br /> Applicants Name (Print) �^ c��C G� Title 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 /> y For July 1, June 30, 19 W <br /> # No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 111 <br /> w R.S. or R.C.E. No. <br /> R.S. or R.G.E. Name <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT �I <br /> Job Address/Location <br /> ,O�w/ner Address <br /> I�.SEPTIC TANK ❑ CESPOOL LEACHING FIELD �YISEEPAGE PIT ❑ PACKAGE PLANT <br /> O(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 /> fi. ❑ 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,D00 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, <br /> - i <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 r an egulations of the San Joaquin Local ealth District. <br /> APPLICANT'S SIGNATURE X X <br /> 5 � s <br /> t <br /> FOR DEPARTMENT USE ONLY t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 11PER SITE . ElEACH .❑ January i &Received By January 31 ❑ July 7 &Received By July 31 <br /> �-� - - REMIT <br /> 5' BASE EXPLANATION BILLING REMITTANCE �'$ AMOUNT DUE CHECKED <br /> DATE DATE -,-`REMITTED AMOUNT <br /> FEE <br /> - LESS <br /> PRORATION <br /> PLUS 4 <br /> PENALTY <br /> OTHER <br /> ( OTHER <br /> eceived by._ Date .Receipt No. Permit Na. Issuance Date Mailed Deliveretl 1 - <br /> APPLICANT—_ RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES y16�01 EE.•HAZ :LT AVE P O.Boer 2009 STOCKTO 201 r <br />