Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. be sure 10algn 111 �+rr <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' hereby ma#carryn buAness)n the'ur. diil area of the SSJoa uln Local Health Dist ict <br /> On Business Name BA) �ess <br /> i OwnerAddressaJ Firm Partners, Addresses and Telephon <br /> 0.a Business Telephone No. Emergency Telephone Na. <br /> Contractor Licence No. <br /> Title Date <br /> Applicants Name (Print) ^.J <br /> Please check Applicable Category(1-7)and Fill in the Required Information r+ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color)_ <br /> CAL. License No. CAL. Lic:.:tse Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD w- ` <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored h # <br /> 3. ❑ PERCOLATION TEST .� <br /> R.S. or R.C.E. Name _ R.S. or R.C.E. No. <br /> Test kation <br /> • Test Date/Time <br /> 4 <br /> 4. El SANITATION PERMIT -7 G <br /> Job Address/Location l` s +�" �- <br /> O_,w Address f 3 ❑ PACKAGE PLAN <br /> Ly SEPTIC TANK ❑ CESSPOOL ��ACHING FIELD - SEEPAGE PIT SPL`,� <br /> ❑/PERMANENT ❑ TEMPORARY L� NEW $❑ REPAIR 11 OTHER <br /> r <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 - <br /> .!—: � -1�1 11 \Type Construction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> r J <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. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f <br /> r <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 r a d regulations of t a J quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ ,lanuary 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 4EE els— <br /> LESS <br /> Received <br /> Mailed De vexed <br /> by Date Receipt No. Permit No, Issuance Da[ r �T <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE., ;Box 2f109 7�nKTQy �� 1 . <br />