Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application is hereby made to carry on business in the jurisdictional area of the San Joe�uin Local Health District <br />rn Business Name (DBA) D%g fl ll L r it (JOr fi n Address -l5) K <br />i Owner Address <br />a <br />Firm Partners, Addresses and Telephone Numbers <br />aBusiness Telephone No. Emergency Telephone No. <br />Contractor Licence No. _ <br />Applicants Name (PrintTitle Date <br />Please check Applicable Category (1-7) and FIII 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 TEST C r IV(_ <br />R.S. or R.C.E. Name K<;rl /� yC--ft/�C- Al R.S. or R.C.E. No. <br />Test Location F! Mr1�r+. Iii >+' c Test Date/Time <br />4. ❑ SANITATION PERMIT e� <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK 0 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. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />G K-4�'.` q 36- <br />I <br />6 <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 repulatt4nspf tgejSan Joaquin Local kiealth 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 />!jf <br />N� <br />�J <br />�zo <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />7' <br />?-i y'6 <br />Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />