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) G f <br /> (dy, SEPTAGE 5�4 't� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio ' h reby a to Qarry on b ness in the jurisdictional area of the San Joaquin cal H It i i t <br /> F Business Uppme (D ) e -� �L � _Add ss <br /> i Owner Address_/&- <br /> a <br /> Firm Partners, Addresses and Te epf_io Nu2ers <br /> aBusiness Telephone No. � 41( Emergency Telephone No. <br /> Contractor Licence No. 4r <br /> Applicants Name (Print) Title Date 7"� '��% <br /> Please check Applicable Category(1-7) and Fill in the&quired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t <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 Location _ Test Date/Time <br /> 4.X SANITATION PERMIT Job Addr s/L tion j <br /> Owner &V Address <br /> Id SEPTIC TANK ❑ CESSPOOL LEACHING FIELD .g SEEPAGE PIT ❑ PACKAGE PLANT <br /> W 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 /> 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. t' <br /> I hereby oertAy that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and a nd regulations of the 2Fan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 11'PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS SC <br /> PRORATION V <br /> PLUS SG(G I <br /> PENALTY `^ <br /> OTHER r`S <br /> OTHER <br /> 0 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deli red <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST CKTON,CA 95201 <br />