Laserfiche WebLink
Applications Will Be Processed When Submitted Properly CompleteBeSure 4 y <br /> APPLICATION <br />'i (For Non-Transferable,Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> L1QU10 WASTE <br /> Application is hereby made to car on bu {ness in the'urisdictional area of the San Joaquin Local Hof th District <br /> Address I �•� <br /> yBusiness Name (DBA) Lid <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. <br /> K <br /> Contractor Licence No. QG Date <br /> Title <br /> r Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)ti <br /> I For July 1, June 30, 19 DIIsposal Sites <br /> l <br /> Description(Make/Yr., Color) �_-.. . <br /> GAL. License No. CAL. License Renewal No. <br /> Serial No, I <br /> Ek Capacity at., Weights &Measures No. r <br /> Equipment Parking Address —� I <br /> 2. ❑ PUMPER YARD <br /> For July 1, <br /> June 30, 19 �� ! <br /> � � k <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored V Q <br /> l 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. ? t <br /> f R.S. or R.C.E. Name 1 1 <br /> TTest Date/Time <br /> Test Location t <br /> I 4. <br /> El SANITATION PERMIT 7 ) <br /> Job Addres /coca i 15 <br /> Address Z' � ` " C <br /> + <br /> )(SEPTIC <br /> ❑ <br /> LEACHING-FIELD ❑ SEEPAGE PIT PACKAGE <br /> ( ❑ PLrANT <br /> ! SEPTIC TANK 1:1 CESSPOOL ❑ OTHER <br /> REPAIR❑ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW _ <br /> i 5. <br /> CHEMICAL TOILETS For July 1, -June 30� 19 <br /> ' Disposal Site t <br /> Type Construction ) U <br /> No. of Units Equipment,Sto une 30, 19ing Location(s) C <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1,, -June 30, 19 Where Certified <br /> Operator Name tt i �_ t <br /> Plant Location <br /> No. Units Served t <br /> � Plant Capacity � — <br /> 7. ❑ LAUNDRY For July 1--June 30, 19 <br /> SIZE: ❑ Less Than 1,0 Sq. Ft.I ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, <br /> at r will be done in accordance with San Joaquin County <br /> k ( <br /> { hereby certify ithat I have repared this ap licatlon and t <br /> ordinances, state laws, and r les and regulat nsof the San J aqui Co al Health District. 1 <br /> I � 7 <br /> I � <br /> APPLICANT'S SIGNATURE X z 1 <br /> FQR DEPARTMENT USE ONLY <br /> r . 31 <br /> Fee Is Due: ❑ ANNUA LY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 �nuary 1 &Received 8y Januar ] Suly 1 Received REMIT <br /> uly <br /> {{ 1LLING REMITTANCE AMOUNT DUE CHECKED <br /> . BRSE [ ,°.,.EXPLANATION •♦� DATE DATE REMIT ED {- y AMOUNT <br /> FEE <br /> +r�j ti mita Q ) <br /> LESS ! c � <br /> o PRORATION r ti <br /> � l <br /> PLUS � .. <br /> PENALTY - �- <br /> f } <br /> OTHER <br /> OTHER <br /> S Z. Mailed Deliver d <br /> Received eye Date i <br /> Receipt Nol� Permit No. issuance Date - <br /> _ _ - 1601 E.HAXELTONAYE.,P.O:BOK 2009 STOIC TON;CA 9 01 <br /> APPLICANT—RETLIRNALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1 <br />