Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />• APPLICATION <br />or Non -Transferable, Revocable, and Suspends.. SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Applicatio 's he eby a e to carr 4iness Int jurisdictional area of the San Joaq��{IRIILgFAi Health �t <br />H Business Norge (DBA) Address-Z&Z.BI /fes/� <br />i <br />Owner-% ✓ �/i SMss /moo �! �Ji G!K✓10.e <br />a <br />Firm Partners, Addresses and Telephone umbers �^ <br />aBusiness Telephone No. — Emergency Telephone No. <br />Contractor Licence No. C l��o <br />L Applicants Name (Print) 4� �� Title �drDate ���� <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, <br />Description (Make/Yr., Color) <br />Serial No. <br />Capacity <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />19 Disposal Sites <br />CAL. License No. _ <br />Gal., Weights & Measures No. <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored <br />CAL. License Renewal <br />3. ❑ PERCOLATION TEST �J /•/L <br />R.S. or R.C.E. Name '44;zgf' .45/OIII R.S. or R.C.E. No. A <:��O!Gr la�o ZcS� <br />Test Location Test Date/Time Z —ZG r <br />4. ❑ SANITATION PERMIT S "1r� -% <br />Job Addre s/Lo tion <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 <br />No. of Units <br />Disposal Site <br />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 <br />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 />No. Units Served <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 San Joaquin Local Health District. <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 <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" <br />Received by ate Receipt No. Permit No. Issuance Date Mailed Delivered <br />. _.........� ..�...... ..........�. r... ..,..,....,......., ..c......c...,t.....I.— .... c ,..ver vnu eve e n a.. m. emnevnu ce ..I <br />