Laserfiche WebLink
APPLICATIONr J <br /> x Non-Transferable, Revocable, and Suspendat <br /> ENVIRONMENTAL HEALTH PERMIT°" SEPTAGE <br /> LIQUID WASTE <br /> Application is reby.made to arry on bu 'ness in the urisdiptional area of the San oaq j Local Health Di Ict <br /> yBusiness Name (DBA) �. ' Addresst 7007J �"" <br /> ? Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. . '�5�� Emergency Telephone No- <br /> �J1 <br /> Contractor Licence No. <br /> L Applicants Name (Print) 2", r� Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <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. <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 /> Testi ation Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> Job Address/I —ation &941K <br /> Owner Address ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD IS EPAGE PIT ❑ PACKAG PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <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 /> 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. <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 rul and regulations of he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �C <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By J <br /> REMIT; <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE k�AMOLI <br /> HECK <br /> DATE DATE REMITTED <br /> FEE IS Il <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu nce Datb Mailed Deli <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO <br />