Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />b�- <br />--- <br />wt (For Non -Transferable, Revocable, and Suspendable) <br />SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />r <br />Application isreby-mmde to ar on busin ss int a jt Ic Tonal area of the oaq n Local Health ' <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J uar .] <br />m ,. <br />v, mousiness Na(15BA) ° . Address.. a 2�7 <br />aOwner _ _ ate'_ AddressS`-- <br />kJ Firm Partners, Addresses and Telephone Numbers <br />a. Business Telephone No. `�� p.5 Emergency Telephone No. .... ... <br />REMtt` <br />i Contractor Licence No. 6 <br />- <br />(Print) _ . _ _ +-��1 Title __ � __ <br />I ApplDate <br />ants <br />JName <br />/ Please check kppticbble Category (1-7) and Fill in the Required Information <br />AMOUNT DUE <br />i 17,p PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />19 Disposal Sites <br />For July 1, - June k--- <br />_ <br />Description (Make/Yr Color) <br />Serial No.���y _ CAL. License No. _.— CAL. License Renewal No. <br />AMOUNT <br />Capacity �`a" '_L3_._... Gal., Weights & Measures No. -_- - <br />! Equipment Parking Address <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 I t <br />ty r <br />0 <br />l <br />No. of Vehicles Stored <br />No. of .Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST <br />k <br />f R.S. or R.C.E. Name R.S. or R.C.E. No.>v -! <br />11v i i <br />Test Location _- Test Date/Time f <br />. <br />4. ❑ SANITATION PERMIT jryc 1 <br />)�a� <br />Job Address/ <br />-. <br />cat <br />O G_ r <br />I� Owner __- Address <br />! ❑ SEPTIC TANK ❑ CESSPOOL ❑ EACHING FIELD <br />S�C1PAGE PIT? P CKAGE PLANT <br />�2 <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW t� REPAIR+ ❑ OTHER I <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19- <br />ype Construction Disposal Site _• __. _ ___— <br />No. of Units _ — Equipment Storage/Cleaning Locations) 1 f <br />- - - - <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 />s .4. R <br />30 <br />I hereby certify that I have prepared this application and•that the work will be doe in accordance W h San Joaquin County <br />nrdacas s- <br />innstate lawand rules and regulations of the SaB dvtfquip Local Health District 'h <br />1 <br />kPPLICANT'S SIGNATURE XIG!--- -- �-" <br />j <br />b�- <br />--- <br />r <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J uar .] <br />eceived By January 31 ❑ Jvly 1 6 Received By July ,31 <br />REMtt` <br />- <br />BASE <br />EXPLANATION BILLING <br />DATE <br />RFMITT <br />DA <br />5 <br />REMITTED <br />AMOUNT DUE <br />CHECKED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />a5� <br />HCCCwCO ny unte ryeceip�{+o. renmi .w. <br />r - APPLICANT -RETURN ALL COPIES TO: ENVIRONM NTAL HEALTH PERMIT/SERVICES <br />t - <br />Issuance Date Mailed - Delivered <br />1601 E. NAZEL70N AVE.; P.O. "x 2009 ST CKTON, CA 95201 <br />N <br />