Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT ' <br /> LIQUID WASTE --� <br /> Application i$r�ar o uslness Int urlsdictional area of theJo uln Local Health Di I i t., [ ))nnI <br /> Business Name (DBA) Address!'+ <br /> i Owner. Address r . <br /> J Firm Partners, AddresseAandTI hone Nur}bersIL <br /> IL Business Telephone:NoEmergency Telephone No. <br /> Contractor Licence No.Applicants Name (PrintTIt1e, _ o_ Date <br /> Please check Applicable Category (1-7);and fIll.in the Required Information „ j j- <br /> .} <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _ <br /> For July 1,' June'30, 19 _ .Y Disposal Sites ._ .,. . <br /> Description(Make/Yr., Color) r... <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 Stored <br /> No. of Chemical Toilets Stored <br /> y T <br /> 3. ❑ PERCOL¢ATION TEST <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. Na <br /> I Test ocation Test Date/Time °3 <br /> e 4: k SANITATION PERMIT " yx <br /> Job Address/ tion 17A 7-44 <br /> efs <br /> ner Address fo <br /> SEPTIC N ❑K CESS OL ❑ LEACH N ._IEL <br /> OD.,_.❑._SEEP AGE.PIT..,;.,.❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY NEW REPAIR n, OTHER jZe#16Cj2-YN el <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site 4 <br /> No. of Units Equipment Storage/Cleaning Location(s)' <br /> 6. ❑ PACKAGE TREATMENT PLAN For July 1, -June 30, 19 �. J <br /> Operator Name ` Where Certified ' <br /> Plant Locationt <br /> Plant Capacity 3 , ." }�?° rNo. Units Served <br /> ws <br /> 7. ❑FLAUNDRY For July 1, -June 30,f 19 w- • �, "" ' <br /> SIZE: ❑ LessThan 1,000 Sq. Ft., ❑ More Than 1,000 5q:'Ft` , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo., _ <br /> I hereby certify that I have prepared this. lication and that the work will be done in accordance with San Joaquin County' <br /> ordinances,state laws, and ru sand re la ons,of ililimn Joaq jpcal Health District. s <br /> APPLICANT'S SIGNATURE <br /> 1a FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT' �o-PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July.31 <br /> _. C.- - I REMIT <br /> : BASE EXPLANATION*�., BILLING FjEMITTANCE $ AMOUNT DUE CHECKED. <br /> DATE' GATE:.-a; REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS '- <br /> PENALTY "" <br /> OTHER <br /> OTHER <br /> Received by Date "f Receipt No. Permit No.. Issuanc Date Mailed ell ered <br /> r+ - <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009" STOCKT N,CA 11 <br />