Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 2b <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Na a (D A) Address <br /> z Owner G In Address 767 -- I <br /> a J <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Ale <br /> s 23� Emergency Telephone No. <br /> Contractor Licence No. c wk ' <br /> L Applicants Name (Print, r Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <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. Licc-lse 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.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time til <br /> 4. ❑ SANITATION PERMIT v <br /> Job Address/Lova ion ` <br /> �Owner Address <br /> y� .� <br /> SEPTIC TANK ❑ ESSPOOLt��LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> �I PERMANENT ❑ TEMPORARY lr� 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 <br /> Operator Name Where Certified <br /> Plant Location — <br /> 4 <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 /> Y <br /> I hereby certify that I have prepared this application and that the work will be dooin a�ccorda a wit San q n �un ah <br /> ordinances, state laws, an s regu aquin Local Hr District. n <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE O <br /> Fee Is Due: 13ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J uary 1 &Received By January 31 ❑ July 1 B Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING HE TANCE $ AMOUNT DUE CHECKED <br /> PATE DATE REMITTED AMOUNT <br /> FEE <br /> l <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> LD 30 Bd 3336 PSCI7,,-5 � <br /> Received by Date Receipt No. Permit No. Issuance Date Maileda ivere <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCK ON,CA 9 01� <br /> i <br />