Laserfiche WebLink
Applications Will Be Processed When Submitted Properly.Completed. Be Sure To Sign The Application.- <br /> APPLICATION <br /> (For Non-Transierable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is here made to carry on business in the jurisdictional area of the San Joaquin Local Health District r <br /> rn Business Name (DBA) A`e, f c� l � Address ! � <br /> z Owner— � Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers , <br /> � J R. - Emergency Telephone No. <br /> 0. Business Telephone No. <br /> ' �Contractor Licence No. <br /> Applicants Name (Print) ' TitleDate rr1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information Ll" <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 14:5- <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic,-nse Rcncwal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,.1.9 <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 /> k Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMiT,--i—� <br /> Job Address/Location <br /> Own%r - T AddressJZ <br /> W SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT _11-TEMPORARY` 0 NEW _. []-REPAIR s�❑ OTHER �- <br /> 5. ❑ CHEMICAL TOILETS For July-1`'-J_unej0, 19 <br /> Type Construction Disposal Site iY <br /> ! No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT -For July 1, -June 30, 19 ; C Uk <br /> U <br /> )- Operator Name ` ' --� ti Where Certified <br /> Plant Location <br /> Plant Capacity --No. Units Served � <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 0, 19SIZE- ❑ Less Than 1!000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> -.-.v.:. _ - s_a..,r�,.re-:,,•.+tmiM arc' f <br /> - 7 <br /> t <br /> f I hereby certify that I have prepared this application arSd that,the work will be done in accordance with San Joaquin'County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> F { <br /> APPLICANT'S SIGNATURE X <br /> T FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Re&ved By July 31 <br /> rt REMIT - <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE a CHECKED <br /> r - -DATE DATE REWTTED AMOUNT <br /> FEE <br /> LESS s <br /> PRORATION <br /> PLUS <br /> PENALTY #- <br /> OTHER <br /> OTHER <br /> i Received by - Date Receipt No. - Permit N0. ,Iss nce Dae Mailed Delivered3—X <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.lIAZELTON AVE.,P.O.Box 2009 STOCKT.ON,CA 05201 <br />