Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSureTosign Inefappnaaav+,. I <br /> i u 1S APPLICATION <br /> .. (For Non-Transferable, Revocable,and Suspendable) SEPSAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional of the5 Joaquin Health District <br /> N Business Name (DBA)�R Address' s r <br /> z Owner Address <br /> a - <br /> j Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> a Business Telephone No. <br /> -J Contractor Licence No.. -U ~I' <br /> Title MA K�A 17 Date. � <br /> LApplicants Name (Print) _T �✓I <br /> Please check Applicable Category (1-7)and F 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.,Color) CAL. License Renewal No. <br /> Serial No. I CAL License No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER HARD <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 bate/Time <br /> Tet Location , <br /> 4. SANITATION PERMIT W "'' w j� t>A ,�'. T )�F <br /> Job Address/Location 5 r`\ -, <br /> Job <br /> + IV[ )!-� ��1 1' i Address <br /> Owner_ 13 GF PLANT - <br /> ❑ SEPTIC TANK 11 CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT <br /> ❑ OTHER �l <br /> PERMANENT ❑ TEMPORARY NEW - )❑?REPAIR <br /> 1> � <br /> ❑`CHEMICAL TOILETS For July 1,*June 30, 19,-t <br /> Type'Construction + Disposal Si Q <br /> ✓ kms.j <br /> No. of Units ' Equipment Storage/Cleaning Location(s) - <br /> s a f 1 .` _ fri <br /> 6. ' P,ACKAGE TREATMENT PLANT For July,1, -June 30, 19'ElC 't t f } �;,Where Certified <br /> Operator Name <br /> Plant Location ' I <br /> r ef'� <br /> No. Units Served: _ <br /> Plant Capacity rf- <br /> 7. ❑ LAUNDRY i For July 1, -June 30, 19 i '4 f , <br /> { fu _ <br /> SIZE: 11Less Than 1,()00 Sq. Ft., More Than 1,000 Sq; Ft. ` <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. ; <br /> Ho+nsownerorlicensed agent's eigrarsr1�ccrtFjPt:.hetoUbmInLI:"Icertity# rtirthenefarnaneedi*h v,,orkferw ichthis permit isissued,lshallriot employ any person <br /> in such manner as to become slibject Iv ri LT-- ,? <br /> Cflntrrsctw's hiring orsub t erF: f. ra s. `. .. ; _IT- <br /> p.2, i.:,.,._ .. k.c i'G< ,i:o :,;,err^i is issueG,1 Shall <br /> E;MP Gy harsolls suh;ecI to: ' .: I <br /> here certif that 1 have prepared this application and 'th4t the work will"be done in accordance with San Joaquin County <br /> Y Y -� <br /> ^f ordinances, state laws, antl ules and reg lations o 'the San 6 Qum Loal Health District. <br /> APPLICANT'S SIGNATURE X� <br /> ... - 6 <br /> +.� Arco— <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> VlFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE + ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 39 <br /> REMIT <br /> t... -«• --„� BASE 'EXPLANATION gDATED TEG# REMITTANCE' $ AMOUN'rDUE CHECKED <br /> REMITTED, AMOUNT <br /> FEE <br /> — <br /> .--` PRORATION _ � - <br /> PLUS <br /> PENALTY <br /> Ile" .r <br /> OTHER '' 0. 1 <br /> OTHER.,.,Fw- <br /> � -Date Receipt No. Permit No. Issuance Dae ailed Delivered <br /> Received-by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM11 ERVICES } 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,GA 95201 <br />