Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> ,. (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i <br /> LIQUID WASTE 1 <br /> Application r her by made to carry on business in the jurisdictional area of thre�Sa Joaquin Local Health District <br /> �LSjA I 50LA Address <br /> Business Name (f?BA) l - � <br /> a Owner Address <br /> 3 <br /> Firm <br /> . Partners, Addresses and Telephone Numbers <br /> Business Telephone No. p Emergency Telephone No. <br /> i <br /> Contractor Licence No. <br /> Applicants Name {Print) f L4 <br /> Title "�`f �.— Date I —` !'t l <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 I <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 Stared <br /> 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 /> Test, Locon A Test Date/Time <br />[ 4. L=i SANITATION PERMIT <br /> E Job Address/Location ) W• C,LpV C <br /> Owner L �- Addressed <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> r <br /> 11 PERMANENT ❑ TEMPORARY NEW 1-1REPAIR ❑ OTHER 'De -=1, , 0L�] "rA1•J1� Y� <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 C-- 1--r-f, ��]le-`Up <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <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 <br /> r <br /> I hereby certify that I hav prepared this application nd that the work will be done in accordance with San Joaquin County ' <br /> ordinances, state laws, a rules and re ations of San J quip Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> S � . <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Fee 15 Dile: ❑ ANNUALLY El PER UNIT ❑ PER SITE EACH ElJanuary 5 &Received By January 31 ❑ July 1 &Received <br /> EMITuVy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i <br /> ' FEE R C/ <br /> LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Assuanct Dat Mailed. Delivered <br /> APPLICANT=RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 C.HAZELTON AVE.,P.U.Box 2009 . TON,CA 85201p� <br />