Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> se.My <br /> APPLICATION , <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> F ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> f LIQUID WASTE 4! <br /> Application is h reby made to carry on business in the jurisdictional area of t San oaquin Local Healt District �LO <br /> t ,�Business Name (DBA) o rr� Address- <br /> >-4_ •�• M1`; . <br /> t a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> I a Business Telephone No. —_4 — ge,d—t Emergency Telephone No. i <br /> I Contractor Licence No. <br /> L Applicants Name (Print)'-4*_rAf4L_1sy I _'stMS Title jEST� A 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 /> 7 R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> r Test Loc 'on Test Date/Time <br /> 4. RISANITATION PERMIT <br /> I Job Address/Location "rte <br /> O�wne c: r Address <br /> One <br /> TANK ❑ CESSPOOL i LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 8 ERMANENT ❑ TEMPORARY O EW ❑ 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) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location j <br /> Plant Capacity No. Units Served i <br /> 7. ❑ LAUNDRY For July 1, -June.30, 19 <br /> "r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. y <br /> a; <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 law rules an egulation f the S Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT L3 PER SITE ❑ EACH ❑ January 1.&Received By January 31 -❑ July 1 $Received By July 31 <br /> f <br /> BILLING REMITTANCE 5 AMOUNT DUE CH CHECKED <br /> REMIT <br /> BASE El(PLANATION DATE DATE REMITTED v <br /> AMOUNT R <br /> FEE <br /> 0. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> l <br /> OTHER (j... <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ance Date y Mailed eliv ed <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON,C 95201 <br />