Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ! APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> • ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati is he ebyf�ade to car on b si ss in the jurisdictional area of th Sian aquln Local Hea strict / <br /> N Business Name (DBA) r rf Address_T _�SUD / <br /> aOwner Address <br /> J Firm Partners, Addresses and lephoCn?e Num ers <br /> C6 Business Telephone No. T ` ! Emergency Telephone No. ^— <br /> v <br /> Contractor Licence No. D <br /> ' Applicants Name (Print) ` Ir Title _ Date 7 <br /> Please check Applicable Category (1-7) andFill 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) <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> i Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 1 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ( <br /> Ne- <br /> _ R.S. or R.C.E. Name ( R.S. or R.C.E. No. <br /> Test ocation i Test Date/Time j <br /> 4. R SANITATION PERMIT E u <br /> Job Address/ oc ion fr Z <br /> Owner HING F +S <br /> Address ' N <br /> ElL � EAC <br /> SEPTIC TANK ❑ CESSPOOIELD EEPAGE PIT ❑ PACKA E PLANT <br /> ❑ PERMANENT ❑ TEMPORARY.j �Z NEW REPAIR ❑ 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 /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> I 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> M. SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals used/Amount/Mo. <br /> �a <br /> 1 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, an rules and r gulatt f the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> 60 <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> i_ <br /> LESS r <br /> PRORATION <br /> 4 PLUS l U <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> 1. L76SUa (V . <br /> RBCeived by Date I Receipt No. Permit No. Issuance Date Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2004 - STOC ON,CA 95201 <br /> :1 , <br />