Laserfiche WebLink
Applications Wilt Se Processed-When Submitted Properly Completed. Be Sure 1osign InenpF+ •• t <br /> ', APPLICATION <br /> (Far Non-Transierable, Revocable,'and Suspendable) SEPTAGE <br /> t - ENVIRONMENTAL HEALTH-PERMIT <br /> �" _ LIQUID WASTE <br /> Application is hereby made to carry n business 0the jurisdictional area of than JoaquinLocal Health ;stri l ) <br /> r Address � "= <br /> HBusiness Name (DBA) <br /> z - Address <br /> Owner . <br /> a <br /> a Firm Partners, Addresses and Telephone Numbers Emergency Telephone No... <br /> CL <br /> Susiness,Telephone No. <br /> Contractor Licence No. <br /> Title Date <br /> C <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information b_ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 - - Disposal Sites- <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. . <br /> Capacity Gal.,Weights &Measures No. ( i <br /> fi <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 4 I <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ' <br /> 3. ❑ PERCOLATION TEST . ..-a <br /> R.S. or R.C.E.No. s <br /> R.S. or R.C.E. Name Test Date/Time <br /> Testi Location <br /> 4. BSANITATIONPERMIT <br /> Job Address cation �, X <br /> { Owner Z) Z tom' Address! <br /> O LEACHING FIELD DSE PAGE PIT ❑ PACKAGE PLAI�iT ' <br /> ❑ SEPTIC TANK, CESSPOOL [ REPAIR El ER } <br /> C PERMANENT ❑ TEMPORARY ❑ NEW <br /> r <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C <br /> Type Construction r Disposal Site # x^' V <br /> No. of Units Equipment Storage/Cleaning Locations) .. <br /> g, ❑ PACKAGE TREATMENT PLANT Fdr'Ju_ly 1,'-'June 30, 19 h'l <br /> " _ i Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity I 4 No. Units Served ir t <br /> 7. ❑ LAUNDRY For July i, -'June 30, 19 <br /> t <br /> SIZE: ❑ Less Than 1,004 Sq{Ft., ❑ More Than 1,000 Sq. Ft. N;� <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. l t <br /> I hereby certify that I taav prepared this pplication and that thew rk will be done <br /> accordance with San Joaquin County t j <br /> ordinances, state law r. d re ations of t Sri 7oa�ui Local Hea"lfh District. <br /> .41 <br /> APPLICANT'S SIGNATURE <br /> �? <br /> FOR DEPARTMENT l}SE ONLY <br /> ived By Juty 31 <br /> Fee is Due ❑ ANNUALLY PER UN El PER SYTE— jE] EACH ❑J nuary 1 &Received 8y January 3i „❑ Jay1 &ReceREMIT <br /> BILLING °f REM1TTfiNCE 4 ?"� Sr�AMOUNT SUE CHECKED <br /> 4BRSE "e P�ANAT101a`l ' dd "PATE '/ "` DATE.y- REMITTED r t,;, .{"' �' - " AMOUNT } <br /> FEE <br /> LESS +✓ I <br /> PRORATION <br /> i <br /> PLUS k } ..,....,......�.. �+,. » <br /> PENALTY <br /> .,OTHER <br /> OTHER <br /> Receipt No. Permit No issuance ale Mailed De4ivered <br /> Received by - Date ._ - "CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE-,P.O.Box 28D9 STOClSTON, <br />