Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign he-App.. <br /> APPLICATION J ' <br /> > (For Non-Transferable, Revocable, and Suspendable) yf <br /> ` — SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT �I� <br /> LIQUID WASTE <br /> Application i hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District i <br /> rn Business Name (DBA) — Address �4 <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. "`��A j Emergency Telephone No. <br /> Contractor Licence No. 2g Zy N <br /> Applicants Name (mint) Title � Date ����' � <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1 �1-13 PUMPER VEHICLEPERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Z . —_ i.. ...144 h L <br /> For July 1, June 30,19 Disposal Sites <br /> Description(Make/Yr., Colon <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> I 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 " � � 1k z t <br /> ¢ - <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ; I <br /> R.S. or R.C.E. Name- <br /> Te <br /> ame. - - . i - T R':S:_oryR:G.Ec No. — <br /> Test L tion, _ ^'" ~� Test Date/Time <br /> 4, LTJ.SAf�11TATION.PERM1 r <br /> 6 ��� �ice, / -'. <br /> Joti Address/Location <br /> Owner n� Address '�90 ��s- <br /> El SEPTIC TANK El CESSPOOL 11 LEACHING FIELD C-SEEPAGE PIT rplai;KAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY ❑ NEW ®REPAIR ❑ OTHER X <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> • Type Construction Dis p <br /> { No. of Units Equipment Storage/Cleaning Location(s) <br /> a <br /> 6. ❑ PACKAGE TREATMENT PLANT For.J,ulyA-;_-June-30;19h <br /> Operator Name Certified <br /> Plant Location y <br /> Plant Capacity No: Units Served. <br /> ± 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., V-❑y More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo..,, <br /> j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> j ordinances, state laws_,_and rules nd regulations of the San boaquin Local Health District, <br /> 4 <br /> APPLICANT'S SIGNATURE X !� <br /> i; <br /> FOR DEPARTMENT USE L�f <br /> Fee Is Due: ❑ ANNUALLY;' ❑ PER UNIT PER SITE_ ,z ❑ EACH ElJan y:1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> /y REMITTED <br /> �{i ,;BILLING REMIT NGE $ - REMIT <br /> 'AMOUNT DUE <br /> BASE EXPLANATION CHECKED <br /> - DATE AT AMOUNT <br /> FEE i <br /> t LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I OTHER <br /> Received by Date - Receipt No. Permit No. Issuance ate Mailed - eliver , <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL H§ALTU PERMIT�RYXFP 1601 E.HAZELTON AVE.,P-O'.Box 2009 .. STOC ON,CA 5201 <br />