Laserfiche WebLink
ApplicationsWill Be Processed When Submitted Properly Completed. Be Sue To Sign The Application. �. <br /> APPLICATION A <br /> (For Non-Transferable, Revocable,and Suspends 'le) <br /> ENVIRONMENTAL HEALTH IPERMIla y/ SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby mto c' on business in the'urisdic,�jonal area of the San Joa uinocal Health Distric <br /> rn Business Name {DBA) Q G �� Address <br /> sOwner Address <br /> Firm Partners, Addresses and T I hq�e Num ers <br /> 4 Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No, <br /> LApplicants Name (Print) Title batefG9 <br /> Please check Applicable Category(1-7) and Fill 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., Calor) (� <br /> Serial No. _ CAL. License No. CAL. License Renewal No. <br /> Capacity— Gal., Weights & Measures No. 4 <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 /> Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT <br /> Job Add ss/Location L),j V <br /> Owner Address .6, p <br /> SEPTIC TANK n CESSPOOL KLEACHINGFIELD FSEEPAGEPIT ❑ PACKAGE PLANT <br /> PERMANENT 13TEMPORARY F NEW ❑ REPAIR ❑ OTHER ` <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 2 <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 <br /> 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, Chemicatg�Used/Amount/Mo. <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, anqZuJqs and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> -,...,Fee Is Due: 11ANNUALLY C1 PE,R UNIT ClPER SITE ❑ EACH EJ January Received By Januar Ja1 &RY 37 © July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE RE TT D AMOUNT DUE CHECKED <br /> �jf �L AMOUNT <br /> FEE" 7 S n r tf / <br /> 5 <br /> iY LESS !.; >• <br /> PRORATION" <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 71 <br /> Received by oat6 Receipt No. Permit No- - Issuance Date Mailed Delivered <br /> t '+ <br /> _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STgCiSTON,CA 952014. <br /> �sr" <br />