Laserfiche WebLink
ApplicationBe 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 />3 <br />c LIQUID WASTE <br />Application is h by made to carry y�o.n business in the jurisdictional area of the an J quin Local U alth ' tr' t <br />U)Business Name (DBA) (sJT T Address- <br />z Owner Address <br />a <br />Firm Partners, Addresses and Telep a um e <br />aBusiness Telephone No. � D Emergency Telephone No. <br />Contractor Licence No. <br />L Applicants Name (Print) 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. 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 />3. ❑ PERCOLATION TEST <br />R.S. or R.C.E. Name R.S. or R.C.E. No. <br />Test cation Test Date/Time <br />4. ASANITATION PERMIT <br />Job Address/ oc tion <br />Owner �F �/ ��s Address + <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING 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 <br />Operator Name Where Certified <br />Plant Location <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 />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, and ruI and regulation f the Sa o uln Local Health District. <br />APPLICANT'S SIGNATURE X 7,0 i4 ' l �[ l,DYYf1 <br />N_)iI <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE, ❑ EACH ❑ January 1 & Received BAouary 31 ❑ July 1 & Received By July 31 <br />BASE <br />EXPLANATION <br />LINt3 <br />REMITTANCE <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />')ATE' <br />J <br />DATE REMIVZGF <br />AMOUNT <br />C <br />FEE <br />Z, <br />J <br />LESS <br />PRORATION <br />S <br />PLUS <br />PENALTY <br />OTHER <br />Ia <br />OTHER <br />- <br />Received by Date Receipt No. Permit No. Issuance Datefled Delivered <br />- ---- -- - ----- -- -.._..__...__.._.. .._.. _.. ___..._,_-_........, •--. - .,t-.�. —, — _- ..nee ern'r w r. ocem <br />r ■ <br />