Laserfiche WebLink
i <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION Y ;� <br /> -tea (For Non-Transferable, Revocable,and Suspendable) SEPTAGE I <br /> i ' <br /> ENVIRONMENTAL HEALTH PERMIT 51 <br /> LIQUID WASTE +� <br /> Application ' erelZy made o carry on siness in the juris ictional area of the Sa Joaqui Local Health Distri <br /> i �1 - <br /> y Business Name (DBA) Address <br /> i Ownerf!' Address <br /> a d. <br /> U Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. �" rC 0 Emergency Telephone No, <br /> Contractor Licence No. <br /> L Appliclants Name (Print) Title Date l� Z�—7 <br /> Please check Applicable Category (1-7)and Fill in the Requireg Information ' <br /> 1. ❑I PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W i <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) j <br /> Serial No. CAL. License No. CAL. Licc,se Renewal No. <br /> • <br /> Capac4.ity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. []!PUMPER YARD Q <br /> For July 1, . - June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test C ation Test Date/Time <br /> 4. SANITATION PERMIT l <br /> Job Adhhdress cation - <br /> iil J G Address <br /> Ow er4 ❑ PACKAGE PLANT <br /> I�EPTIG TANK ❑ CESSPOOL `EACHING FIELD SEEPAGE PIT <br /> PE'R' MANENT ❑ TEMPORARY 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 4 <br /> Operator Name Where Certified a <br /> Plant Location II <br /> Plant Capacity No. Units Served 0 <br /> 7. ❑i LAUNDRY For July 1, -June 30, 19 <br /> SIZE: �i ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I 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, and rules regulations of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> i rye. <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT �/�.PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i OTHER I. <br /> OTHER # <br /> C�L <br /> Received by Date Receipt No. Permit No. Iate Mailed De vered <br /> ssuance . <br /> APPLICANT—RETURN AI. LL COPIES TO: ENVIRONMENTAL HEALTH PERMIT! ERYI ES 1601 E.HAZELTON AVE.,P.O.Box 2009 .STOCKTO ,CA 95201 <br /> �- //- .s r -.q <br />