Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ; <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati�r is��jj er y madet arry o businessAn the jurisdictional area oft Sa oaquin Local Hea h District i <br /> ,F Business Name (DBA) (y.�-t• � _ Address <br /> I'_ Owner J11Address <br /> j Firm Partners, Addresses and Telephone Numbers F <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 3 - j <br /> L Applicants Name (Print) !I Title �S I Date d <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) • I� <br /> Serial No. I�� CAL. License No. CAL. License Renewal No. <br /> i <br /> Capacity IiGal.,Weights & Measures No. <br /> Equipment Parking Address �! rt <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 !� <br /> No. of Vehicles Stored .: <br /> No. of Chemical Toilets Stored it <br /> 3. 13 PERCOLATION TEST # <br /> R.S. or R.C.E. !Name '.! R.S. or R.C.E. No. <br /> Test Lncation 11 Test Date/Time <br /> 4. VSANITATION PERMIT ' <br /> Job Addres Location - <br /> Owner Address �� + <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD %SEEPAGE PIT ❑ PACKAGE PLANT t <br /> 9PERMANENT ❑ TEMPORARY ❑ NEW 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) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 0 Where Certified <br /> Plant Location II <br /> Plant Capacity 11 No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Jun`e 30, 19 <br /> SIZE: 11 Less Than 1,000 Sq. Ft`, ❑ More Thar1 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules and r gula s f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` ` <br /> �I t <br /> if FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> I� DATE DATE REMITTED AMOUNT <br /> dd <br /> FEE <br /> LESS <br /> PRORATION n <br /> PLUS - <br /> PENALTY I 17-1 r l t <br /> OTHER <br /> OTHER II <br /> I� •© s93� � <br /> C' S . <br /> Received by 'Date lii Receipt No Permit No. suance Date Mailed yved ALLCOPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009C79121/1 — <br /> APPLICANT—RETURN I <br />