Laserfiche WebLink
rt —'Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ilk v <br /> APPLICATION <br /> �4 w <br /> r, (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made t c on bu iness'nth juris fictional area of the San Joaquin Local Health District <br /> Business Name BA) Address 7,6 7 <br /> .4 Owner Address <br /> Firm Partners, Addresses and Telephone Numbers 7 <br /> I a Business Telephone No. �O Emergency Telephone No. <br /> i -j Contractor Licence No. <br /> d / <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required formation i U <br /> t 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> k Serial No, CAL. License No. CAL. Uccnse Renewal No. <br /> #t Capacity Gal., Weights & Measures No. i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> f 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Dation Test Date/Time <br /> 4. Ila SANITATION PERMIT �. <br /> Job Address/Locatia ' <br /> Owner <br /> Address <br /> ❑ SEPTIC TANK ❑ CESS OLACHING FIELD ��EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑-REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> E 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 /> P <br /> Operator Name Where Certified ` <br /> t Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30i 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. !, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 'I <br /> ,, <br /> ! I hereby certify that I have prepared this application and that the work will be done in accordant San Joaquin County <br /> ordinances, state laws, and rules a regulations of the oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> � FOR DEPARTMENT USE ONLY li <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT SITE ❑ EACH ❑ anuarg eceived By January 31 ❑ July 1 &Received By July 31 <br /> I BILLING REMIT $ REMIT <br /> BASE EXPLAN ION PATE DA REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS r <br /> PRORATION t <br /> PLUS <br /> PENALTY <br /> a _ <br /> OTHER <br /> s , <br /> OTHER <br /> rYk <br /> Received by Date Receipt No. Permit No. s uance Date Mailed Deliver d W <br /> - APPLICANT—RETURN ALL COPIES TO� ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE_.,P.O.Box 2009y� STOC ON,CA 5201, F <br />