Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. . <br /> - APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) j <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby pade to arl prLbusiness in the jurisdictional area of the 5 oaquinlLLocal Health District <br /> ,�Business Name (DBA) . 1 ruLG-(� Address <br /> aOwner Address <br /> L) Firm Partners, Addresses and Telephone Numbers —.---_� <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �*-�� <br /> L Applicants Name (Print] - fGL Title ��. Date 4������ r <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 /> i <br /> Serial No. CAL. License No. CAL. Liccriso Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> _ a <br /> No. of Chemical Toilets Stored ' 1 <br /> 3. ❑ PERCOLATION TEST_ <br /> R.S.°vr R.6.E; Name R.S. or R.C.E. No. <br /> Test Location ` €est Date/Time <br /> 4. ❑.-SANITATION PERMIT _ <br /> Job Address/Location <br /> Owner aDr d tAddress <br /> 11 SEPTIC TANK 1:1CESSPOOL ❑ LEACHINGfliELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR/ ❑-OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -.Jun-e-30, 19 <br /> Type Construction 7 `_Disposal Site f. <br /> No. of Units` Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE-TREATMENT,PLANT For July 1,'-June 30,.19 f <br /> M 's <br /> • Operator Name � � � "�' - ��' ' Where Certified i— <br /> PlanfLocation <br /> Plant Capacity s t No. Units Served 1 <br /> 7. ❑ LAUNDRY For July 1, ;JLri'e 30, 19 / <br /> SIZE: ❑ Less Than,1,000 Sq._Ft., 016ore Than 1,000 Sq. Ft. - <br /> ❑ DRY CLEANING- Chemicals Used/Amo�i nVMo. <br /> l <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 lam, and rules and regulatns f the SaJoaquin Local Health District. } <br /> APPLICANT'S SIGNATURE X ' <br /> 1 . <br /> v FOR DEPARTMENT USE ONLY <br /> -.Fee Is Due: 1:1ANNUALLY ❑ PER UNIT [IPER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Deceived By July 31 <br /> ■ REMIT <br /> BILLING REMITTANCE $ <br /> - BASE EXPLANATION: - - AMOUNT DUE _ CHECKED <br /> DATE DATE REMITTED ( AMOUNT <br /> FEELIS I Ole <br /> # <br /> LESS <br /> PRORATION _ <br /> t PLUS iI , <br /> —PENAL-T,,Y -x ,_ s T_ <br /> OTHER V/1, <br /> y <br /> OTHER 1r - - _ ' _ -.._ ti -. _-. xl <br /> 4 Y <br /> 3.,, <br /> Received by - Date Receipt No. Permit No. - ss nee Dat Mailed ,N Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES 1601 E.HA ELTON AVE.,P.O.tigx 2009 sTOCKTON,GA 9520Y�X <br /> r <br />