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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application?, h, eb ade to c r(on usiness in he jurisdictional area of the an Joaquin Local Health District <br /> !�( !7 Ed � fl7i/J f J Address TO Pix <br /> OF Business Name (DBA) �0• -- cc, }�(- <br /> z Owner Address _ <br /> J Firm Partners, Addresses and T le hone Numbers <br /> CL Business Telephone No. � 0Emergency Telephone No. I <br /> -J Contractor Licence No. l <br /> �Applicants Name (Print) Title �S Date <br /> r <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I �� <br /> For July 1, June 30, 19 I Disposal Sites <br /> Description(Make/Yr., Color) 7 F <br /> i <br /> Serial No. CAL. License No. CAL. Licc-tse Renewal No: <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, Y 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 /> r <br /> Test ocation Test Date/Time <br /> 4. SANITATION PERMI r o <br /> Job Address/ ocation �-4 <br /> o er Address <br /> 4 SEPTIC TANK ❑ CE POOL LEACHING FIELQ SEEPAGE PIT ❑ PACKAGE PLANT s: <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-Jeune 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 f <br /> Operator Name 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, Chemicals Used/Amount/Mo. <br /> Y <br /> hereby certify that I have prepared this application and that the work will be done in accordaVice with San Joaquin County <br /> ordinances, state laws, and Wes and re u tions o e ayt J n Local Health District. J r <br /> APPLICANT'S SIGNATURE X r <br /> JA <br /> t <br /> . FOR DEPARTMENT USE N Y t <br /> Fee Is Dile: ❑ ANNUALLY [I PER UNIT. -PER SITE ❑-EACH Eln ar Received By�January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMIT A E $ AMOUNT OUE CHECKED <br /> DATE REMITTED <br /> _ AMOUNT <br /> i <br /> FEE Y� <br /> LESS <br /> PRORATION j <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> t <br /> -- OTHER <br /> d 5$ �,' 3. <br /> Received by Date _ -• R ipt No. Permit No. Issuance Date Mailed beliver9d <br /> APPLICANT—RETURN ALL COPIES TO: ' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009, STOC 71ON,CA 9 201 I <br />