Laserfiche WebLink
Qm Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i reby made to arry on bu ' ess in he' ris ' tional area of the S Joa in Local Health Distri <br /> OF Address , �" <br /> Business Name (p ) <br /> z Owner 2 Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. —r �51�r� Emergency Telephone No. <br /> Contractor Licence No. Z <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Req red 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 /> 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�L�ation Test Date/Time <br /> 4. Z SANITATION PERMIT M <br /> Job Address/ cat"on <br /> /4 <br /> Owner Address ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ;S6 PAGE PI ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 111REPAIR ❑ OTHER <br /> 5. ❑ 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 /> 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 accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION AMOUNT DUE CHECKS DATE DATE REMITTED <br /> AM UNT <br /> EEE 4S l Ly <br /> LESS ofO <br /> PRORATION '1 <br /> PLUS <br /> PENALTY <br /> OTHER �J <br /> OTHER +� } <br /> v v�� <br /> Received by Date Receipt No. Permit No Issu nce D to I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:4 >4 <br /> 9 SyOCK�TyO�Ny,�CA 95201 <br />