Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> qA. (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I LIQUID WASTE <br /> k Application is ereb ad t carry on busi in the ju s c�tional area of�I e San Joa m Local Hgglth i ict <br /> k w Business Name {DBA) �S Address x �� r✓�� L — <br /> I z Owner Address <br /> 1 Firm Partners, Addresses and Te epho Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> i L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information (37: <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. Lic se 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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> 1 Test Location Test Date/Time <br /> 4. W SANITATION PERMIT r `7 <br /> Job Address/Location >rh l 1r <br /> Owner Address <br /> SEPTIC TANK 11CESSPOOL ❑ LEACHING FIELD 11SEEPAGE PIT C1 PACKAGE PLANT <br /> E ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) a <br /> 6. ❑ 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, 1.9 <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, a J rules and regulations of the San Joaquin Loca Health District. <br /> a flue, <br /> I APPLICANT'S SIGNATURE X <br /> 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 /> REMIT <br /> FILLING REMITTANCE $ MOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> - DATE - DAT REMITTED AMOUNT <br /> FEE <br /> F LESS <br /> S PRORATION - <br /> PLUS <br /> PENALTY -- <br /> OTHER <br /> k <br /> OTHER <br /> f <br /> ' Received by - ate Receipt No. Permit No. Issuance Date' Mailed I <br /> L� De ivere , <br /> m APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL` PERMIT/SERVICES - - 1661 E.HAZELTON AVE,P.O Box 2009 STOCKT N,CA 95 I <br />