Laserfiche WebLink
.V. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> -•- b•r (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i • ere4y mad to carry on business in the' risdictional area of thejaan Joaquin Local Health Di ct <br /> mBusiness Name (D (L Add ress <br /> 4 Owner Address <br /> Firm Partners, Addresses and Telephone Numbers I <br /> CL <br /> Business Telephone No. C) Emergency Telephone No. <br /> Contractor Licence No. " <br /> Applicants Name (Print) Title �1`�"r'� Date ��� �� <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse P,encwal 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 /> 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 L ation Test Date/Time i <br /> 4. El SANITATION PERMIT <br /> Job Address/ cation a " <br /> I O�wn� µ Address r 'lam <br /> S. TIC TANK ❑ CESSPOOL ,, L`E CHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY M-IVEW ❑ REPAIR <br /> 13 OTHER N <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 <br /> Where Certified <br /> Operator Name I <br /> Plant Location pr <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. <br /> i <br /> 1 <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 laws, and rules and r ulations o the S oaquin Local Health District. �C <br /> APPLICANT'S SIGNATURE X <br /> C <br /> I FOR DEPARTMENT USE ONLY t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Ja u r &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE- EXPLANATION BILLING REMI E $ AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> �FELESS <br /> PORATION <br /> PLUS <br /> PENALTY { <br /> f <br /> OTHER <br /> OTHER ffjj <br /> t V� ka <br /> • <br /> Received by Date Receipt No. Permit No. Asuance Date Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO <br />