Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION Jb <br /> (For Non-Transferable, Revocable,and Suspendable) SEpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 0 <br /> LIQUID WASTE <br /> Applica ' i bye o c busij�uns i tonal area of the San Joaquin L al Health Dis ict <br /> ,,Business Name (DBA) 1�4 �s Addre /�120 `S 'S <br /> z Owner r Address 7- 19,9� r <br /> a <br /> Firm Partners, Addresses and Telephone Numbers — <br /> a. Business Telephone No, Emergency Telephone No. } <br /> Contractor Licence No. � <br /> L Applicants'--Name{Print]s Title <br /> C;��� Date <br /> Please check Applicable:Cdtegory(1-7) and Fill in the Required Information �J . <br /> 1. ❑PUMPER VEHICLE"PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 Disposal Sites <br /> r <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 Stored ' ('A <br /> i <br /> No. of Chemical Toilets Stored Y <br /> i 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name n0 R.S. or R.C.E.No. 1n <br /> Test Location Test Dale/Time <br /> 4. X SANITATION PERMIT t <br /> Job Addre s/Location T <br /> Owner I !✓� f,E6� - Address S <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEXCHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ 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 t <br /> Operator Name W eh re Certified <br /> Plant Location `" <br /> No. Units Served <br /> Plant Capacity �-� <br /> 7. ❑ LAUNDRY For.July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br /> ❑ DRY CLEANING�Chemlcals-,eed/Amount/Mo. <br /> 'V.{.� t : <br /> I hereby certify tha prepared this application and that the work willbbdaccordance with San Joaquin County <br /> ordinances, sti laws, les and regula " ns ofth San Joaquin Local Health Districts <br /> APPLICANT'S SIGNATUR y< <br /># FOR DEPARTMENT USE ONLY. _ <br /> Fee Ispue:,L7,ANNUALtY_q Fj,UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED r <br /> �.� FFF DATE DATE' REMITTED AMOUNT <br /> �T �y'V% � y� <br /> FEELESS <br /> Tc <br /> PRORAON r t <br /> 1 PLUS 11 t <br /> PENALTY <br /> OTHER <br /> OTHER / <br /> 7 <br /> K <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deli red <br /> APPLICANT—RETURN ALL COPIES To: '.ENVIRONMENTAL HEALTH PERMIT/sfRVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST KTON, A 95201' " <br />