Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE ° <br /> Applicatio here y m e to carry o business 0 the jurisdi tonal area of th San oaquin Local Heal strict <br /> m Business Name (DBA) r ` ' CAddress t/l <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Num ers <br /> a. Business Telephone No. EmergencyTelephoneNo.. ` <br /> Contractor Licence No. <br /> Applicants Name (Print) Title ��., ...___ Gate 7 � 1 <br /> Please check Applicable Category (1-7) and Fill in the Required Information i <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 i <br /> 2. ❑ PUMPER YARD I <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 /> Te s ocation Test Date/Time I <br /> 4. SANITATION PERMIT I <br /> Job Addres ocati n 24 <br /> Owner Address - . <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 'KNEW ❑ REPAIR ❑ OTHER <br /> ❑ 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 l <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 /> 7 <br /> 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 ru s and regulat ns of the Joa in Local Health District. <br /> APPLICANT'S SIGNATURE X <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 J31y 31 <br /> BILLING REMITTANCE $ REMIT ' <br /> BASE - EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED f <br /> AMOUNT , <br /> FEE ys <br /> LESS ' <br /> PRORATION <br /> { <br /> PLUS ;7 <br /> PENALTY �� �•� �� <br /> 1 I <br /> OTHER COL 4 <br /> OTHER <br /> Received by '%,Date Receipt NO. Permit No. -- Issuance Date Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST CA 95201 <br /> M, <br />