Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> i LIQUID WASTE <br /> Application is reby made carry on business in the jur dictional area of the San Joa uin Local Health Distr' t <br /> ,�Business Name {DBA Add re 74 <br /> z Ownerk ' Address ` <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> aBusinss Telephone No. :S-� O-� Emergency Telephone No. - 4 <br /> �Contractor Licence No. <br /> Applicants Name(Print) - Title _�J Date Z`�� <br /> Please check Applicable Category (1-7) and Fill in the Requir d Information j <br /> 1. PUMPER VEHICLE PERMIT-REGISTRATION (FOR EACH VEHICLE) <br /> y .r <br /> For July1, �-_ June 30,'19 I' Disposal Sites <br /> Descrilption(Make/Y,r., Color) it <br /> Serial No. _ CAL. License No. CAL. License Renewal No. <br /> Capacity � w j _ 1 Gal., Weights & Measures No. y i <br /> Equipment Parking7A d ssl ' <br /> 2. ❑�PUMPERrYARD wt <br /> For July 1, June 30, 19 . <br /> No. ofthicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑1PER OLATION TEST <br /> R.S. 01 E. Name �I. R.S. or R.C.E. NO.: <br /> Test L cation I� Test Date/Time a I <br /> 4. SANITATION PERMIT j) <br /> Job Addr Location /.77".7 �-� <br /> O�w er�i� Address <br /> u� S�3h IC TANK ❑ CESSPOOL ,� LL CHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> L�PERMANENT ❑ TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> r <br /> 5. ❑'CHEMICAL TOILETS For July 1, -June 30, 19 ; <br /> Type Construction ' # f <br /> Yp .� Disposal Site _ <br /> No. of Vnits :!f Equipment Storage/Cleaning Location(s) ` <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> i�•M <br /> Plant Capacity R No. Units Served L <br /> 7. 11 {LAUNDRY For July 1, -June 30, 19 <br /> SIZE- I ❑ Less Than 1,000 Sq. Ft'� ❑ More Than 1,000 Sq. Ft. , t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. •_ <br /> I hereby certify that I have prepared this application`andxthat-th' a rrvork. ill-be-done in accordance with San Joaquin County <br /> ordinances, state laws, andruI d regulations of the o quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> II FOR DEPARTMENT USE ONLY <br /> Fee Is Due., ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ n y &Recei d January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> p BASE IE EXPLANA ION BILLING REMITT NCEAMOUNT DUE CHECKED ` <br /> } Il� DATE TE MITTED t <br /> i AMOUNT <br /> FEE <br /> LESS �' E <br /> PRORATION II, <br /> PLUS I <br /> PENALTY <br /> D�pHER <br /> OTHER ll <br /> �F <br /> II / 6 <br /> Received by - Date it Receipt No. Permit o. - Issuance Date Mailed De ive d <br /> A?PLiCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO AVE.,'P,O.Boll 2009 - STOC TON,CA 95 01 <br />