Laserfiche WebLink
d Completed.Oe awe <br /> ..,...e.. .... �. <br /> . ApPilodbns will Be Processed When Su�AmPtltPLICATION SEPTAGE <br /> r (For Non-Translerable,Revocable,and Suspendable) <br /> ENY,IRONMENTAL HEALTH PERMIT • <br /> r LIQUID WASTEDistrictSJw �Y.w/ <br /> sdictional area of the San Joequln Local Health <br /> Application is hereb�il ado to carryon business In the Jp Address �� / - <br /> /e iD TD <br /> Business <br /> ams(DBA) Address <br /> aOwnef Emergency Telephone No. <br /> Firm Partners,Addresses and Telephone Numbers ' Q� — <br /> $�cosiness Telephone No./¢ s Dates t <br /> Titl6 d.-'t- <br /> j Contractor Licence No. _ <br /> Applicants Neme(Print 1 7 and Fill in the Required Intormellan , <br /> Please check AppliesWa Category( 1 <br /> 1• ❑ PUMPER tlEHICLE PERMIT REGISTRATION(I CSites <br /> t�HICLE) <br /> For July 1 June 30-19 1 No, <br /> CAL.Ueense Renews <br /> Description(MakelYr•'Coior) CAL,License No. " <br /> Serial No. Weights&Measures No. <br /> I Gal.,Weig <br /> Capacity <br /> Equipment Parking Address } <br /> i g, ❑ PUMPER YARD i <br /> 1 For July I,—JNne 30, 19 <br /> yk No.of Vehicles Stored <br /> No.of Chemical Toilets Stored _ R.S.or R.C.E.No. <br /> 3, Q PERCOLATION TEST <br /> A.S.or R.C.E.Name Teat Data Time <br /> Test Local //�� yn' �, FFA <br /> ! q• Va SANITATION PERMIT /,gw,Gin..�e.i'I �'I'll,"L---" � - <br /> Job Add" ` - U PACKAGE PL/.,•.. <br /> Owner l�/� BCt' �2. ❑ LEACHING FIELD A BE PIT <br /> Q CESSPOOL ❑ REPAIR [2 OTHER <br /> SEPTIC TANK ❑ NEW <br /> ' '1C PERMANENT d TEMPORARY <br /> 5, 0 CHEMICAL,T0ILETS For July 1.-June 30, IDisposal Site <br /> ` Type Construction Equipment Storage/Cleaning Locations) <br /> F No.of Units ---------� July 1 June 30, 19 Where Certified <br /> 5. Q PACKAGE TREATMENT PLANT F <br /> or ; , <br /> Operator Name <br /> I Plant Location No units Served <br /> ! Plant Capacity <br /> -1. 0LAUNDRY For July 1,-June 30. 9 <br /> S000 ' hat1,D00 Sq.Ft. <br /> I SIZE: Lass Than 5, Sq.Ft., ❑ MoreT ) . <br /> �1 Q DRY CLEANING,Chemicals Used/AmounUMo. <br /> application and that the work will be done In accordance with San Joaquin Counly <br /> i. I hereby certify that 1 have prepared'.this <br /> I ordinances,,state Is and rules and regulation t the San Joaquin Local Health District. <br /> .1 APPLICANT'S SIGNATURE <br /> ble <br /> FOR DEPARTMENT USE'ONLY By <br /> JanoalY 1&ReeelvBC BY January 31 ❑ July <br /> 1 8 flecely REMIT July 31 <br /> ` t7 PER UNIT 1. 0 PER SITE ❑ EACH $ AMOUNT DUE CHECKED <br /> Fee IF Due:.Cl,ANNUALLY BILLING REMITTANCE REMITTED <br /> AMOUNT <br /> "•r BASE EKPLANATION DATE DATE <br /> r <br /> FEE <br /> PPORATION <br /> PLUS <br /> PENALTY <br /> - ' OTHER -r/p� <br /> OTHER .. I �V <br /> 6/(/eJ l (J Manna � De,;verea <br /> t Perm I No. .HAZ2La Dale STMKTOK dA tel <br /> ' RecNPI No. 1p1 E.HAZFLTON ATF•:P.O.9oL 7ao9� <br /> Recel by <br /> ENVIRONMENTAL HEALTH PEPMIT/S <br /> APP LICANT—aETUNN A0.COPIES TO: ERVICES <br />