Laserfiche WebLink
ApplicationsjWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. `- <br /> APPLICATION ; <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> r ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> li LIQUID WASTE <br /> A plication ereby de to car on ess int is nal.area of the S in Lo ealth D t <br /> OF Business e ( A) /Address I <br /> aOwner Addre sE� O+ <br /> a Firm Partners, Addresses and T�leLrhoeNumbers '�� C�. <br /> a 41- <br /> Business Telephone No. (9.Ave Emergency Telephone No. <br /> Contractor Licence <br /> LApplicants Name (Print) C Title �Ge)��'+ Date i <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 I Disposal Sites <br /> Description(Make/Yr., Color) �I <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I! <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored II <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name ;� R.S. or R.C.E. No. r <br /> Testi La tion Test Date/Time <br /> 4. I�SANITATION PERMIT 111 <br /> Job Addre Loca ion Q - <br /> Opper I� Address <br /> r�_SEP TAN ❑ CESSPOOL Zl LEACHING FIELD C-E-EPAGE PIT 11 PACKAGE PLANT L1 <br /> PERMANENT ❑ TEMPORARY QINEW ❑ REPAIR ❑ OTHER ­71' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction .!I. Disposal Site <br /> No. of Units II Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name �A Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ftj ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i� <br /> I hereby certify that I have ar d this applicatio d that the ork wilftbe do in accordance with San Joaquin County <br /> ordinances, state laws, a rules d regulations of a oa in Local Ie t istrict. <br /> APPLICANT'S SIGNATURE X ! <br /> it FD DEPART4NT SE ONLY <br /> Fee Is Due: <br /> El ❑ PER UNIT PER SIT ❑ EA•H January 1 &Received By, ry 31 ❑ JWy 1 &Received By July 31 <br /> BASES EXPLANATION BILLING REMITTANCE $ REMIT = , <br /> DATE DATE REMITTED AMOUNT DUE AMOUNT <br /> CHECKED <br /> FEE # <br /> LESS <br /> PRORATION it <br /> PLUS <br /> PENALTY I' <br /> OTHER I� <br /> OTHERe_1 1 04C <br /> II <br /> Received 6y Date �� Receipt No. Permit No IssUancerDa e Mailed Deliva'. r J <br /> APPLICANT-RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT N,CA 95201 a <br /> 1u <br /> "i� <br />