Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. be Sure To Sign The Application. <br />APPLICATION <br />(For Non -Transferable, Revocable, and SuSpOndable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />. . . I I Lj­�+h ni.trirt <br />Application !a$Nrebymade 1P carry on business in the ;Untidictional area of the wrijOaqUin <br />Address <br />nusiness Narnie <br />P 2GAddress <br />z Qwner_ <br />C <br />Firm Partners, Addresses and Telephone Number <br />Business Telephone No. <br />yTelephone No. <br />• <br />Contractor Licence No. <br />Title VMS 7— <br />Applicants Name (Print.) <br />Plea" check Appllllbi8catsqory 0 -7) and Fill In the AequirecCillmation <br />PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE), On <br />For July 1, _11�-Jina 30.. 19 Disposal Sites <br />Description Mako/Yr:, . ....... <br />Serial No, J CAL.License Renewal No____, <br />CAL. License No. fj <br />I <br />Capacity . ... .. 4 Gal., Weights Measures No. <br />Equipment Paiking'Adaress --7- <br />2. 0 PUMPER YARD <br />For July 1_ June 30, 19 <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored <br />3. 0 PERCOLATION TEST.' <br />A.S. or R.C.E. Name A.S. or R,C'ENo. . ...... .. <br />Test Location Test Date/Time <br />4. OSANITATION PERMIT <br />-ss oca ion-_ <br />Job Address/Coca <br />Owner . .... .. Ad4dres;__Li�__L3_1__fA)_ <br />cja <br />_,,on <br />• SEPTIC TANK ESSPOOL �LEACHING FIEL 0 PACK' GE PLANT I- *ft <br />CE <br />• PERMANENT 13 TEMPORARY 0 NEW I V REPAIR 0 OTHER <br />13 CHEMICAL TOILETS For July 1, - June 30, 19 <br />pe Construction Disposal Site <br />,io 011 Units <br />Equipment Storage/Cleaning Location(s) . . ..... <br />,— - - — ___ <br />6. 0 PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name WhIpre Certified <br />Plan', Location <br />Plant Capacity. NO. units Served ........ <br />7, 0 LAUNDRY For July 1, - lune 30, 19 <br />SIZE. 0 Less Than 1,000 Sq, Ft,, 0 More Than 1,000 Sq, Ft. <br />Cl DRY CLEANING, Chemicals Used/Amount/Mo. <br />I hereby certify that I ha" PrePgnid this application and that the work will be done in accordance with Joaquin County <br />ordinances, state laws, and rules and regu ions of the San quip Local fleafth 01strict, <br />&ZI&AZ9 - — .. . ......... <br />APPLICANTS SIGNATURE X <br />FOR DEPARTMENT USE ONLY <br />3 <br />, 2 <br />ri MA*;i"T LIPERSITF Cl F.Acti 0 1 OrY " & " Ived By JaluarY 31 juiy i a Receivea ey juiy 31 <br />ran up 138. ANN J <br />BASE <br />I _­­ <br />CXPLANA140N <br />..." �EMti7A3+i ",- _T_: I <br />BILL NGAMOUNI <br />. ...... . ... <br />NT 04, <br />REMIT % <br />CHD- <br />DATEOA <br />AFEMITTE0 <br />AMOUNT <br />FEE <br />—LESS -7 <br />PRORATION <br />PLUS <br />PENALTY <br />OTkSR <br />OTH90 <br />. . ........... <br />fi <br />mved by Data jpt NO. No, �HAZFLTO>�W. P. <br />APPLiCANT=RETUAN AL 06PIES TO,. ENVIA ft " <br />AL HEALTH ITISEAVICfS <br />