Laserfiche WebLink
4 Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f y APPLICATION 11 <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE q <br /> Appiica is h reb ade to carry on usiness in the jurisdictional area of the San Joaquin Local Health District _ <br /> Business Name (DB 5r4 llc-� _Address s` Se �.� -f27 <br /> a Owner + Address 5 J / <br /> J Firm Partners, Addresses and rrelephone Numbers <br /> cBusiness Telephone No. so S r (a Emergency Telephone No. <br /> j Contractor.,Licence No. .3 <br /> �Applicants`Name(Print)'• Title 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, y r 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 /> 21-,E] PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.1of Vehicles Stored <br /> ,'%of Chemical Toilets Stored }` <br /> 3. ❑ PERCOLATION TEST ' <br /> R S:"or R.C.E, Name R.S. or R.C.E. No. V) <br /> F O <br /> est�yrLocation Test Date/Time <br /> 4� •pl SANITATION PERMIT / • !, � <br /> JobAlA <br /> ddre )/Location SID D e-/� <br /> Ofr+._ &V ! <br /> wner _ _Addressz C <br /> 0 SEPTIC TANK ® CESSPOOL ,. KLEACHING FIELD R SEEPAGE PIT ❑ PACKAGE PLANT <br /> �9K PERMANENT ❑ TEMPORA.RY'` ❑ NEW 11 REPAIR El OTHER <br /> , 54 ❑ CHEMICALTOILETS For July 1, -June 30, 19 <br /> Type Construction i Disposal Site <br /> No. of UnitsF Equipment Storage/Cleaning Location(s) <br /> 6�, ❑ PACKAGE'TREATMENT;PLAN T For July 1, -June 30, 19 <br />!' Operator Name ) Where Certified j <br /> Y <br /> PlantLocation <br /> Plant Capacity } ( No. Units Served <br /> or 7. ❑ LAUNDRY For July 1, -June 30,t19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> l hereby certify that.I hav epared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,�state laws, nd r le �a d regulatio s!f the 5 Joaquin Local Health District. <br /> 1 <br /> .APPLICANT'SyyIiSIGNATUREX f <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER;UNIT PE E,� ❑ EACH ❑ January 1 &Received By January 31' ❑ July 1 &Received By Jury 31 <br /> �fiI BILLING REMITTANCE $ REMIT <br /> BASE <br /> !EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE r <br /> LESS t a <br /> PRORATION <br /> PLUS <br /> PENALTY . -� <br /> OTHER y f <br /> OTHER ' f . <br /> .7 a� r <br /> Received by Date Receipt No. Permit No .Issuance Date' Mailed De" a ed - 1 <br /> 'APPLICANT—RETURN.ALL COPIES TO:�ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 2009 ST CKTON, A 85281 <br />