Laserfiche WebLink
r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> k APPLICATION <br /> I 4, 1 (For Non-Transferable) Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Rppl ication is hereby made to Carr <br /> y on business in the jurisdictional area of the San Joaquin Local Health District <br /> r Business Name (DBA) % �' Address <br /> N ! r <br /> aOwner (• " Address <br /> 1 Firm Partners, Addresses and Telephon Numbers v t <br /> I a Business Telephone No. _ I� - Emergency Telephone No. _ ., <br /> -i Contractor Licence No. 6_6 1 <br /> OE�,�r.Li Date — <br /> L Applicants Name (Print) Title' = <br /> Please check Applicable Category (1-7)and Fill in the Required Information ,r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Fdr July 1, June'30, 19 Disposal Sites <br /> Description(Make/Yr.. Color) — iRenewalSerial No. CALFLicense No:"" ' " CAL-License No. <br /> Capacity Gal-,Weights &Measures No. <br /> Equipment Parking Address <br /> i,; , ' ' •L <br /> i 2. ❑ PUMPER YARD <br /> For July 1, R June 30, 19 <br /> No. of Vehicles Stored <br /> 4 <br /> No. of Chemical Toilets Stored <br /> i 3. ❑ PERCOLATION TEST ., y <br /> R.S. or R.C.E.Name a;'. R.S. or R.C.E.No. I <br /> ' ( Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location _ _ <br /> O.wn�r d Address <br /> SEPTIC TANKS ❑ CESSPOOL EACHING FIELD ❑ E PIT C3 PACKAGE PLANT <br /> I <br /> 11 OTHER'. <br /> 13PERMANENT ❑ TEMPORARY- =0 NEW <br /> i 5. ❑ CHEMICAL(TOILETS For July 1,-June 30,19— <br /> Type <br /> 0, 19Type Construction <br /> f <br /> No. of Units Equipment E ui ment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 # <br /> - »Where-Certified <br /> Operator Name —�—= <br /> I 3 <br /> l Plant Location <br /> Units_Served <br /> Plant Capacity # No. ; -;,,,k •,�� - , <br /> 7. ❑ LAUNDRY i For July 1, -June 30, 19 I # <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 11 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t £ <br /> I hereby certify that I have prepared this application and that the Work will be done in accord nce with San Joaquin County <br /> ordinances, state laws, and rules and r uta ions o the San Joaquin Local Health District ;z v'-w- <br /> APPLICANT'S <br /> -w- <br /> APPLICANT'S SIGNATURE X�-� � �_�. � ���. �� � - --• <br /> ! 1 <br /> FOR DEPARTMENT USE ONLY <br /> ( i <br /> Fee Is Due: ❑ ANNUALLY ©�PER UNIT © PER SITE .. ❑ EACH ❑ January 1 &Received By January 31 ❑ Jury t Received By July 31 - <br /> y REMIT <br /> .BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE- CHECKED <br /> DATE .DATE -- R TTEb F` .AMOUNT <br /> FEE <br /> LESS r <br /> PRORATION <br /> PLUS I i <br /> PENALTY - { - <br /> OTHER <br /> OTHER t J Y <br /> r� fr <br /> Received by _ Date .Receipt No. �� Permit No..,n'�_� 1 uance to - Mailed Delivered - <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES, 1601 E.HAZELTON AVE.,P.O.Box 2609_ $TOCKTON,CA 95201 <br /> :q - <br />