Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />or Non -Transferable, Revocable, and Suspenda <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />AppliAand. <br />by de the r n sines the Lrisdic <br />FBusine me(DBA�01 B55 0 <br />Owner I A dress, <br />Firm Partners, AddreDho Nury rs <br />aBusiness Telephone No. 1 <br />Contractor Licence No. <br />Applicants Name (Print) fon <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. _ <br />Capacity <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />Gal., Weights & Measures No. <br />area of <br />Emergency Telephone No, <br />Title <br />SEPTAGE <br />Date <br />CAL. License Renewal No. <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored ` F <br />3. ❑ PERCO TION TES�� <br />R.S. orRCE Na e R.S. or R.C.E. N <br />Test Location -..r� r Test DateMr <br />4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction <br />Disposal Site <br />SEEPAGE PIT ❑ PACKAGE PLANT <br />REPAIR ❑ OTHER <br />No. of Units Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name <br />Plant Location <br />Plant Capacity <br />7. ❑ LAUNDRY For July 1, - June. 30, 19 <br />No. Units Served <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />Where Certified <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 and regulations of the Sao Joaquin Local Health District. <br />APPLICANT'S SIGNATURE <br />FOR DEPARTMENT USE OW <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 <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 />C 7�1Z —7 oL1 <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />ALL COPIES TO. <br />