Laserfiche WebLink
keel Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION s <br /> (For Non-Transferable, Revocable,and Suspendable) j <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE 0 <br /> LIQUID WASTE <br /> Application is erpby mad to carry on usiness in the juri ctional area of the San Joaquin Local Health Distri t <br /> Business Name (DBA Address e <br /> z Owner Address <br /> 4 <br /> 1.Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - - S l 0 Emergency Telephone No. <br /> ' Contractor Licence No. 32,f Z z__ I p J <br /> �Applicants Name (Print) Title Date <br /> I Please check Applicable Category (1-7)and Fill In the Req ed Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) U? <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic,Anse 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 Stored <br /> No. of Chemical Toilets Stored <br /> I 3. ❑ PERCOLATION TEST <br /> f R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test�cation Test Date/Time <br /> 4. [?] SANITATION PERMIT <br /> Job Address/ ation <br /> Ow er Address <br /> _ PTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> i ❑ <br /> � PERMANENT ❑ TEMPORARY 11 NEW ❑ REPAIR OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> f 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 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <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 rules and egulations of the n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> E FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMITD <br /> BASE <br /> EXPLANATION DATE DATE REMITTED AMOUNT UE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r OTHER <br /> Received by Date Receipt No. Permit No. I suance Date Mailed De wer i r <br /> { APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEIT/SER CES 160 STOCI( ON,E.HAZELTON AVE.,P.D.Box 2009 CA 95201 <br /> _ <br />