Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTneApplication. <br /> l� APPLICATION <br /> - (For Non-Transferable, Revocable, and Suspendable)—66�- SEPTAGE j <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE r <br /> Appli do is reby mad to corn business in the jurisdictional area of th San Jo quin Local Health District O <br /> wBusiness Name (DBAi-,r - - s� "' S Address r t <br /> aOwner Address <br /> J Firm Partners, Addresses and T a ephone Numbers <br /> abusiness To No. O Emergency Telephone No. - <br /> Contractor Licence No. r <br /> Applicants Name (Print) TitleI� 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, <br /> CAL License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> 1 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> t <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. Or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> � <br /> Test Date/Time <br /> Test Location <br /> 4. k] SANITATION PERMIT <br /> Job Addr�s Location <br /> Owner Address , <br /> ❑ SEPTIC TANK ❑ CESSPOOL_ ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT hh__ <br /> ❑ PERMANENT ❑ TEMPORARY 11NEW ❑ REPAIR X OTHER �&�B�C�A/ <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 /> Where Certified <br /> l Operator Name <br /> If <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 ules and re lations of the San Joaquin Local Health District" <br /> APPLICANT'S SIGNATURE X c� > <br /> FOR DEPARTMENT USE ONLY P <br /> +. <br /> t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 8 Received 8y January 31 July 1 S ReceiveTDUECHECKFD REMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ .AMOUNT <br /> DATE DATE REMITTED NT <br /> ys <br /> r. FEE <br /> LESS { <br /> PR09ATION <br /> PLUS <br /> PENALTY -� <br /> OTHER <br /> I <br /> OTHER " <br /> I• Received by Date Receipt No. w _ Permit No. - Issuance Date Mailed e"v red- I <br /> I APPLICANT—RETURN ALL COPIES TO:{ ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON-AVE.,P.O.Box 2009 ST KTD A 41 { <br />