Laserfiche WebLink
^r'Flffd QLFUns will tseProcessedWhen Submitted Properly Completed. Be Sure To <br /> APLICATION Sign The Application. <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Business Name 13A) iness in th <br /> sEPrAGE <br /> Appislication ereby made to car on b e'uris tional area of the San Joaquin Local Health District <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Num ers Address <br /> a Business Telephone No. <br /> c.r/p <br /> aContractor Licence No. Z-Z Emergency Telephone No. <br /> L Applicants Name(Print) <br /> Please check Applicable Category (1-7)and Fill in the Requir Information Title Date 1- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) , t <br /> k <br /> For July 1, June 30, 19 6- <br /> Description(Make/Yr„ Color) Disposal Silos <br /> Serial No. <br /> Capacity <br /> CAL. License No. CAL. Lic;,,,se Renewal <br /> Gal., Weights & Measures No. <br /> Equipment Parking Address rt <br /> 2• ❑ PUMPER YARD <br /> For July 1, June 30, 19 ~� <br /> �r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored. <br /> 3• ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name + <br /> Test-LO ation R.S. or R.C.E. No. <br /> 4. � SANITATION PERMIT Test Date/Time <br /> Job Address/ ion <br /> Owner <br /> ❑ SEPTIC TANK ❑ Address '. 4 <br /> CE P OL LEACHING FIELD ❑ SEEE <br /> ❑ PERMANENT ❑ TEMPORARY EJ NEW PAGE PIT ❑ PACKAGE PLANT <br /> 5. 1:1 CHEMICAL TOILETS For July 1, -June 30, 19 �EPAIR ❑ OTHER 04 <br /> Type Construction Disposal Site <br /> ora <br /> No. of Units d <br /> 6. 11EN <br /> PACKAGE TREATMT PLANT EForpment July 1St June 0, 191ng Location(s) F <br /> Operator Name k <br /> Plant Location Where Certified <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July , -June 30, 19 1No. Units Served <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 <br /> ordinances, state laws, and rules a regulations of a San Joaquin Local Health District accordance with San Joaquin County <br /> APPLICANT'S SIGNATURE X z_ <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> ❑ EACH ❑ January 1 R Received By January 31 4 <br /> _ ❑ Juiy 1 &Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ - REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED o <br /> FEE AMOUNT <br /> LESS <br /> Q <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Received by Date Receipt No. <br /> errnit o Issu nce to Mailed APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered <br /> ,1601 E.HA2ELTON AVE.,P.O.Box 2009 ST9PKTON,C�A95 201 <br />