Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureToSign 1nexppiIcauvII. <br /> APPLICATION 1"31211" <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE 1�1 <br /> ENVIRONMENTAL HEALTH PERMIT 49, <br /> LIQUID WASTE <br /> Application i hereby m de to carryon business in the jurisdictional area of the San oaquin Local Health District _ <br /> F 1, t�GG� Address 4-1 <br /> N Business Name (DBA} f, <br /> z Owner_. 4 i 4• =r✓ -L�—� Address <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> aBusiness Telephone No. 'd Emergency Telephone No. <br /> Contractor licence No. r _ <br /> Applicants Name (Print) /=i6' Z.� Title d 2' Date <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 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc.;,se Renewal No. <br /> Capacity I Gal.,Weights & Measures No. ` <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,' June 30, 19 <br /> No. of Vetiicles Stored_ _ <br /> No. of Chemical Toilets Stored,\ s <br /> 3. ❑ PERCOLATION TEST. <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location — Test Date/Time <br /> 4. ❑ SANITATION PERMIT / W <br /> Job Address/Location --- <br /> O <br /> Owner Address <br /> EPTIC TANK r ❑ CESSPOOL EACHING FIELD ❑ SEE GE orr '❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY' ❑ NEW EPAIR ❑ OTHER Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -'June 30, 19 4 <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 <br /> Operator Name 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. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Nxlt <br /> I hereby certify that I have prepared this application and that the work will be done in acco,rdance with San Joaquin County <br /> ordinances, state laws, and rules and re �s of the San Joaquin`Local Health District. <br /> op <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ^ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ­ <br /> 4 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -.1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95207 <br />