Laserfiche WebLink
Ilcations Will Be Processed When Submitted ProperlyCo <br /> - <br /> 'jW <br /> APp <br /> APPLICATION <br /> + (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i reby�made to carry on usine s the juri ctional area of the SanJoaquin Local Health Dis i t <br /> Address <br /> Business Name (D ) <br /> Address <br /> z Owner. <br /> a <br /> i Firm Partners, Addresses and Telephone Neu/O Emergency Telephone No. <br /> fIL <br /> a. Business Telephone No. <br /> Contractor Licence No, <br /> Date <br /> Title _ <br /> �Applicants Name (Print) <br /> iPlease check Applicable Category (1-7 and Fill in the Required 1 formation <br /> } <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR <br /> o BACs Sites <br /> VEHICLE) <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL. License No. CAL. Licz.nse Renewal No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> �. A <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> l No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.G.E. No. <br /> R.S. or R.C.E. Name - Test Date/Time <br /> TestL ation q <br /> t q, SANITATION PERMIT (. <br /> Job Address/ aion ddress <br /> Ow r LD �SEPAGE PIT ❑ PACKAGE PLANT <br /> T SEPTIC TANK ❑ CESSPOOL LEACHING F ❑ OTHER RAIR <br /> LJ PERMANENT ❑ TEMPORARY ❑ NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> g. <br /> 13 PACKAGE TREATMENT PLANT For July 1,-June 34, 19 Where Certified <br /> i <br /> Operator Name <br /> Plant Location No. Units Served <br /> I 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. <br /> . ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> k <br /> i <br /> 7 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Goun y <br /> ordinances, stake laws; and sand regula ' ns o e San Joaquin Local Health District. <br /> F <br /> APPLICANT'S SIGNATURE X <br /> I <br /> I FOR DEPARTMENT USE ONLY <br /> PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 - -❑ July 1 &Received By July 31 <br /> I, Fee I5 Due: ❑ ANNUALLY ❑ REMIT <br /> NATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION I BASE DATE DATE REMITTED AMOUNT/ <br /> $ $1 v <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' OTHER <br /> ^c , Issuance Dae Mailed elivere f <br /> Date - Receipt No. .. Permit No. <br /> Received by - 1601 E.HAZELTON AVE.,P.O.Boz 2008 STOCK ON CA 9/5201 <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER MI7ISERYICES /�� `/� /��/ - '7/ 1 <br />