Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, 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 Joaquin Local Health District <br /> ,;Business Name DBA) - r Address <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telep one Numbers <br /> CL Business Telephone No._ fir Emergency Telephone No. <br /> a Contractor Licence No. f <br /> �Applicants Name (Print) - Title Date <br /> Please check Applicable Category (1-7)and Fill in the Requir d Information r; Q <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) is ;; ;r,, r;i,J 1, i;; 1 Calif. 9vc07r <br /> For Jul 1, June 30, 19 Disposal Sites „- ;�.. <br /> y A' —019 <br /> a Lit:,-fi' b. <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> TestLocation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/ cation , <br /> O er �� Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE ANT <br /> XPERMANENT ❑ TEMPORARY WNEW C3REPAIR OTHER <br /> S. ❑ 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 /> Where Certified <br /> Operator Name <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 /> I hereby certify that I have prepared this application and that the work will be done in ace dalgr' Sart Joaquin County <br /> f ordinances, state laws; a Azin1d regulations of the San Joaqu' Local Health District. 1 n <br /> APPLICANT'S SIGNATURE X r <br /> C�.;',R" <br /> •ft. :).;---�c::+� �,�.._i'�i:(i7s 5 lu,i.=Ci7 x <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> Illlil REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTEDn <br /> AMOUNT <br /> FEE <br /> LESS <br /> fff PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Iff <br /> Received by D to Receipt No, Permit No, I u e Da Mailed Delivered <br /> APPLICA T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZE AVE.,P.O.Bo.2809 STpCNTON,CA 95 <br />