Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The App lca fi . <br /> „J <br /> APPLICATION • <br /> (For Non-Translerable, Revocable,and Suspendable) SEPTAGE <br /> ENVM0NdtNTAL HEALTH PERMIT <br /> LIQU10 WASTE <br /> Applicatio is hereby made to car bu 'n in the jurisdictional area of the S oa Local Health trict <br /> N Business a DBA Address i <br /> � I <br /> ad.[d e <br /> JA j Firm Partners, Addresses and Telephone Numbers tC � W <br /> a Business Telephone No. Emergency Telephone No. I <br /> a <br /> Contractor Licence No. <br /> Title 0(Z lj e Date <br /> i <br /> Applicants Name (Print) ' <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) CAL. License Renewal No. <br /> Serial No. — " <br /> CAL. License No. ` <br /> - i <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address C1 <br /> 2. ❑ PUMPER YARD V� <br /> For July 1, June 30, 19 91 + <br /> No, of Vehicles Stored <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 /> Test Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT <br /> Job Address/ ocation <br /> Address 5 <br /> I caner C TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ��/ <br /> a PERMANENT 13 TEMPORARY g NEW ❑ REPAIR C1 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 j <br /> Where Certified <br /> I Operator Name <br /> Plant Location <br /> I' <br /> No. Units Served <br /> Plant Capacity <br /> F 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> f 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 p ared this a plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an es and regu ns f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY [3 PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 [3 July 1 &ReceiveRdEByl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED . <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> x <br /> Date Receipt No. rP,er�mit No. O Issuance Date Mailed Deli red <br /> Received by 1601 E.HAZELTON AVE.,P.O.60 09 ST KION,CA 95201 <br /> APPLICANT_RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />