Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Com <br /> APPLICATION pleted.Be Sure To Sign The Application. <br /> f� r <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> !/ LIQUID WASTE <br /> r Applicatio i e by m eto arty on business n th jurisdictional area of the an Joa uin a <br /> C �44 q c, �lealt�Pl�tact <br /> y Business a e BA) ��N�l Address G �( <br /> aOwner Address <br /> .Firm Partners, Address42aing,;,ig7lehone Numbers 6`�"'a Business Telephone No1dc47 13 <br /> Emergency Telephone No. <br /> Contractor Licence No.. <br /> Applicants Name (Printn Title i°Q 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. y ,_ :CAL. Licznse Renewal No. <br /> Capacity Gal„ Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ,I" <br /> For July 1, June 30, 19 .. ' .... , <br /> No. of Vehicles Stored +' 4 I q <br /> No. of Chemical Toilets Stored "� YS... t <br /> 3. ❑ PERCOLATION TEST v <br /> i <br /> R.S. or R.C.E. Name R.S. or R.G:E. No, <br /> Test Location �� Test Date/Time <br /> A. % 5ANlTA710N PER IT 'S- f <br /> Job�Address cation ��L I] LON ,..�ti��.� <br /> r <br /> Owner �� Address' G 6 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD,,,- . SEEPAGE PIT '.❑ PACKAGE PLANT � <br /> PERMANENT E] TEMPORARY NEW REPAIR 3❑¢OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 k f <br /> Type Construction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) ,. r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19" <br /> Operator Name Where Certified <br /> Plant Location 3 [ <br /> Plant Capacity No. Units Served 4 ; <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 � ti'= <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. y <br /> s <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and re io �11, Jo q 'n�Loa��ealth District. ' <br /> } ' <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE .❑ EACH, ❑ January'1 &Received By January 31 ❑ July 1 &Received By July 31 r <br /> BILLING+ IIT _ REMIT A <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE j '�, "BATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION a ` <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> Received by ate Receipt No. ermit N /Issuarift Date Mailed D d } <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONJAVE.,P.O.Box 2009 <br /> TOC 95201 <br />