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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE !' <br /> LIQUID WASTE <br /> Ap-plicatiorLis her by �odeto c�rry on usiness i the jurisdictional area of the an Joaquin Local ealt. istrwt <br /> yBusiness Name (DBA} c �D7i Address r ' <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Teft! one mbers <br /> Business Telephone No, Emergency Telephone No, <br /> Contractor Licence No. _ 1543 <br /> L Applicants Name (Print) r Title xfS_ Date <br /> Please check Applicable Category (1-7)and FIII in the Required Information p <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. CAL. License Renewal No. t <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 /> 4 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> O er rT4ti t O Address u T J <br /> SEPTIC TANK 11CESSPOOL IJLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Iz PERMANENT 13 TEMPORARY NEW REPAIR 11 OTHER r <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 h <br /> Operator Name Where Certified <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. j <br /> hereby certify that I have prepared this application and that the work will be done in ac it once with San Joaquin County <br /> ordinances, state laws, a d rules and r gulatio o the Sa aquin Local Health Dis i i <br /> APPLICANT'S SIGNATURE X ° jk <br /> OT FOR DEPARTMENT SE NLY <br /> Fee Is Due: 1:1 ANNUALLY O Y ❑ PER UNIT PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Heceived 8y July 31 <br /> BILLING ITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED _ <br /> 14 AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER l <br /> i <br /> b �a d 4� <br /> Received by Date Receipt No. Permit No. lssuanc43 Date Mailed a ive d <br /> APPLICANT—r1ETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,C 95201 <br /> J <br />