Laserfiche WebLink
A ~. Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transierable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> — LIQUID WASTE <br /> 4 Application is hereby ade to carry on business+n the jurisdictional area of the San Joaqu cal DistrictHe�� ` <br /> mBusiness Name (DBA) c — n-u"`� a Address_7_Tr <br /> aOwner r l .l�� Address `� <br /> u- Firm Partners, Addresses and Telephone Numbers <br /> 00' Business Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name {Print) Title * Date <br /> g <br /> Please check Applicable Category (1-7) and Fill in the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) x <br /> For July 1, June 30,19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. Llc:.nse Renewal No.° <br /> " Capacity _' Gal., Weights &Measures No. -- <br /> �. f r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of.Vehicies Stored <br /> , <br /> I 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 /> kTest L Ion Test Date/Time : f <br /> F s._ <br /> 4. Lff SANITATION PERMIT <br /> Job Address/Lotion / <br /> Owner C !�L Address es <br /> b PTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ,,, f ❑ REPAIR DITHER .J'4./r <br /> Ili PERMANENT ❑ TEMPORARY 11 NEW � - <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Site <br /> Type Construction Disposal �— <br /> No. of Units Equipment.Storage/Cleaning Location(s) <br /> t 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> I Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. { <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 ules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �Y•/>�'�� <br /> e <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH Cl 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 /> I EEE <br /> LESS 'Z <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permi ,No- Issuance Date Mailed De rvere <br /> x' ..APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,,P.O.Box 2009 STOCK N,CA 9 <br />