Laserfiche WebLink
.i <br /> Applicelions Will Se Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> r (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> (.'QUID WASTE <br /> Application is rep rr„�,,.r,usin ss q the jurisdictional area of the S J�Qa a ocal Heal h Dist t <br /> a <br /> Business�(DBAIA_ee- <br /> (� ��'/TL/ ��/. <br /> 1d i Owner J�iG� �1 //// Addres -- <br /> Address -2"1/ <br /> u Firm Partners, Addresses and Telephone Numbers �.c K -S*'Lr/te � <br /> y i Business Telephone No (JC�� 3�� <br /> 6 �S�j Emergency Telephone No. SN't-- <br /> Contractor Licence No. JW S" 7.z/ — - <br /> -- - <br /> Applicants Name(Print) c CiC Sr�rEl ---� <br /> £ Title .AW-A)*_ - Date -�- <br /> Please check Applicable Category(1-71 and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) f <br /> For July 1, -__June 30. 19 Disposal Sites _ <br /> Description(Make/Yr.,Colorl - - - -- --�Q <br /> Serial No. - --- ---- <br /> CAL.License No. CAL.License Renearal No. <br /> Capacity _ _ _ - Gal.,Weights 8 Measures No. ___ --- <br /> Equipment Parking Address __ - <br />"# 2. ❑ PUMPER YARD -- -- j <br /> 1 t <br /> For July 1, _ June 30. 19 av ,yz��rCS•„' < .'` ``" <br /> No.of Vehicles Stored <br />;i <br /> No.of Chemical Toilets Stored <br /> rte# 3. ❑ PERCOLATION TEST -- -` --_ --- _ <br /> of <br /> R.S.or R.C.E.Name _ _-- R.S.or R.C.E.No. <br />< Test Location Test Date/Time _ -- ------- 9 <br /> 4. SANITATION PERMIT 1 - -- - - Y <br /> Job AddressiLocation <br /> Owner Address C.� �_-------- - ---- <br /> t ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br />' 5. ❑ CHEMIC/,L TOILETS FC.July 1,-June 30, 19 <br /> Type Construction----- Disposal Site <br /> No.of Units -------___.-_ __ <br /> ______. _ _ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 --- <br /> Operator Name - —Where Certified <br /> Plant location --___-_-_ _ _ ------------------16*j <br /> Plant Capacity -----------------_ , <br /> 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. 3 <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Ma <br /> I hereby certify that I have pts, .d this applic on and that the work will be done in accordance with San Joaquir,County <br /> ordinances,state laws,a ruI anJ gulatio e n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑PER UN17 ❑ PER SITE ❑EACH January 1 8 Rtp B <br /> -' _ y January 31 ❑July 16 Recewed By July 31 <br /> .--REMIT <br /> BASE EXPLANATION BILLING REMITTAN E t' f AMOUNT DUE CHECKED <br /> DATE DATE ( REMITTED <br /> FEE G I - <br /> L O - - -_ -_ AMOUNT <br /> LESS \-.. -- - - --- <br /> PRORATION / - - <br /> -- <br /> PLUS <br /> PENALTY <br /> OTHER -- ------ - -- <br /> OTHER - -- - - - --- --- - - _ <br /> �1�eCs�Wf1 by------ - Dna HrcmpC l No .__` d`(—_[_-_ —v"^ I -_—Ma11W <br /> fd ' aua tb <br /> APPLICANT—RETURN ALL COPIES TO: r.NVIRONMFNTAL HEALTH PERMITISERVICtf 1201 E.I'HAZILTON AVE,P.O.nos 2000 SyOCKTON,CA"201 <br />