Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. BeSureToSignTheApplication. <br /> - " APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Na (DBA) Address <br /> z Owner _ Address�-Z'�? f- 7-le C <br /> a <br /> o Firm Partners, Addresses and Telephone Numbers f <br /> aBusiness Telephone No. G /1 � Emergency Telephone No. k <br /> Contractor Licence No. 3 <br /> LApplicants Name (Print) --q �- Title d Date <br /> Please check Applicable Category (14) 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. Lic4,se Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address 1 <br /> 012. 11PUMPER 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. i <br /> Test Location Test Date/Time t i <br /> 4. ❑ SANITATION PERMIT •. � .1; <br /> Job Address/Log4tionX <br /> Owper Addresses ' <br /> L ' EPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> Lff PERMANENT ❑ TEMPORARY NEW x ❑ REPAI'Ry}�� ❑ OTHER <br /> June �I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 `%, O" <br /> Type Construction I Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locatil-O'i(s)-""" <br /> 6. ❑ PACKAGE TREATMENT PLANT For,July 1, -June 30, 19 / <br /> I 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 /> g <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 rut nd regulations ofjt4 San Joaquin Local Health District. <br /> I. APPLICANT'S SIGNATURE X ` <br /> ~ FOR DEPARTMENT USE ONLY <br /> 4 Fee Is Due: ❑ ANNUALLY ❑ PER 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 <br /> DATE DATE REMITTED AMOUNT <br /> 1 /mss <br /> FEE i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> F OTHER <br /> Received by Date Receipt No. PV7o. 7� suan e Date Mailed Deliv red ° <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/S&A�ES ( .1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON, A 95201 <br />