Laserfiche WebLink
s� Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppucauon. <br /> -w. APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE d <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,n Business Name (DBA) Address <br /> 4645 11ild-reth Lan <br /> rp -P <br /> a Owner Address <br /> 1 <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 931 97 Emergency Telephone No. 9 5.7-4027 � <br /> J <br /> -j,Contractor Licence No. 308171 <br /> L Applicants Name (Print)_ ' Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information # <br /> 1 � Pf1MPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sitesa <br /> Description(Make/Yr., Color) _ `_ ' <br /> Serial No. CAL.-License No. 'KCAL. Liccr�:le Renevral No. , <br /> Capacity t Gal., Weights & Measures No. <br /> , <br /> Equipment Parking'/Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, +" June 30, 19 <br /> No. of Vehicles Stored <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 Location Test Date/Time W- <br /> 4. ❑ SANITATION PERMIT t Q' <br /> Job Address/Locati <br /> An Fr Addressr (� , <br /> SEPTIC TANK' CESSPOOL LEACHING FIELD ❑I SEEPAGE PIT 13 PACKAGE PLANT <br />± ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPKI�R' ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 - " <br /> Type Construction Disposat Site <br /> 4 No. of Units Equipment Storage/Cleaning Locati on(s) <br /> w 6. ❑ PACKAGE TREATMENT PLANT For`July 1, -June 30, 19 <br /> I Operator Name � f � Where Certified <br /> Plant Location v . <br /> Plant Capacity No Units Served <br /> i 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. +.r <br /> I �• r <br /> I hereby certify that I r <br /> this application an he work will be done in accordance with San.Joaquin County <br /> ordinances, state laws, egul -the Sa +n-Local Health Distri { E _s <br /> APPLICANT'S SIGNATURE X <br /> fr —FOR DEPARTMENT USE ONLY z <br /> Fee IS Due: 0 ANNU LLY ❑ PER.UNIT d I�PER SITE 0 EACH 0.January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 4 —: REMIT .. <br /> BILLING REMITTANCE s y AMOUNT DUE CHECKED <br /> a BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS } <br /> PRORAT4ON - <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES � 1 E.HRZELTON AVE.,P•O.90=2009 STOC ON,CA 5111 <br /> -- <br />