Laserfiche WebLink
6�Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y <br /> APPLICATION `II <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application hereby mape to carry on business in thejupsdictionai area of the San paquin LocalHealth Distr' tt i <br /> FBusiness Name Address Address <br /> z Owner_ <br /> z <br /> JFirm Partners, Addresses and Telephone Numbers <br /> I Business Telephone No. 96 <br /> C!-sd Q j Emergency Telephone No. <br /> a <br /> Contractor Licence No. Date ^� <br /> Applicants Name (Pring Title <br /> Please check Applicable Category (1-7)and Fill in the Requ+red Ilnlor ACH VEHICLE) <br /> 1. El PUMPER VEHICLE PERMIT REGISTRATION (FOR ECLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color)'j'" CAL. License Renewal No. <br /> Serial Nom <br /> i CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, <br /> Jima 30}19 - <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ` <br /> 3. O-PERCOLATION TEST"` "�`�" " % r} <br /> R.S. or R.C.E. Name' °° iso -�- � =� '-, R.S.or R.C.E;.No: <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT ` <br /> Job Address/ o ation af � n Q ° <br /> Owners Address <br /> ❑ SEPTIC TANK O CESSPOOL ❑ LEACHING FIELD If�SE AGE PIT 11 PACKAGE PLANT <br /> 11 PERMANENT 1:1 TEMPORARY D NEW EPAIR OTHER <br /> ! h <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19- <br /> Type Construction ?Disposal Site_ <br /> No. of Units Equipment.Sto ar gel/Cleaning Locations) <br /> E 6. O PACKAGE TREATMENT PLANT For Juiy 14-June 30, 19 1 i <br /> 1 Wh"ere-Certified <br /> Operator Name I t <br /> Plant LocationI <br /> i w � No. Units 5efved <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 11Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> h ❑ DRY CLEANING, Chemicals Used/Amount/Mo. I <br /> I hereby certify that I have prepared this application andthat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule nd regul igps oft an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X C(/� <br /> FOR DEPARTMENT USE ONLY 4By <br /> �• <br /> e <br /> Fee-Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuIy 31 <br /> F <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r DATE DATE REMITTED AMOUNT <br /> FEE <br /> r LESS <br /> PRORATION ,p <br /> PLUS ' <br /> PENALTY r1 <br /> i <br /> OTHER �1 <br /> OTHER �� r <br /> Received by Date Receipt No. Permit No, Iss nce ate Maile Delivered <br /> 4 - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O. 2009 - Sj.00KTON CA 95201 <br />