Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />or Non -Transferable, Revocable, and Suspend. SEPTAG{ <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application if;tlefeby{n>1de to carbon b3ksjueAin the jurisdictional area of thg•1SA J,Oacjy{inkogal F�a�j}�1pistri <br />r 1 W r��t��� X11 7nZi �� -I— <br />k4 <br />I Owner 5C ddress <br />V Firm Partners, Addresses and Tel ho a Numbers <br />aBusiness Telephone No. Emergency Telephone No. <br />Contractor Licence No. _ <br />L Applicants Name (Print) G T'tte Date r,Z <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. License Renewal No. <br />Capacity Gal., Weights & Measures No. <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TELST •1n <br />R.S. or R.C.E. Name r/ I��IC 1 iJ ./ V R.S. or R.C.E. o. <br />Test Location Test Date/Time - - <br />4. ❑ SANITATION PERMIT <br />Job Address/Location - - - - <br />Owner Address - - <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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 <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 <br />11 DRY CLEANING, Chemicals Used/Amount/Mo. A- <br />V_ <br />vo'- <br />I hereby certify that I have prepared this application and tha rill N <br />ordinances, state laws, and rules and regulations of the San Joaq ocal He <br />a <br />APPLICANT'S SIGNATURE 1 <br />.\ <br />with San Joaquin County <br />FOR DEPARTMENT USE ONLY <br />Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Com— rI c>� <br />Received by ale Receipt No. Permit No. Issuance Date Mailed Delivered <br />. __.._..._ ..�...... ..........«.... �..,e......��r...�..... ece..a,�ce,nrcc ..,,. c ,.,ee, mu eve en e... enna emrrmu ee ocont <br />