Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicat' n i her y mad, to r on b smess in t e jurisdictional area of the an J2pquin Local Healt Ist ct _ <br /> h Business Name (DBA) Address 7sy rnJz+a� <br /> zz Owner Address <br /> J Firm Partners, Addresses and 4 hon Numbers <br /> aBusiness Telephone No. 3 3 _ _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date "ko <br /> Please check Applicable Category (1- and Fill in the Required Information Q r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites �aaJ1I <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 /> 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 /> Test Loca .on Test Date/Time <br /> 4. CJ SANITATION PERMIT <br /> Job Address/ ocatio �-� <br /> Owner <br /> cess <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHE/R� <br /> 5. 13 CHEMICAL TOILETS For July 1, June 30, 19 {/ M.e / <br /> � <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 hav prepared this application a that the work will be done in accordance with a6'aquin County <br /> ordinances, state laws, r les an gulatio f t an oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> CAI <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Recei January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE <br /> ASE EXPLANATI DATE DATE ITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed 'Dehv4er?flZAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC <br />