Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t APPLICATION <br /> t K (For Non-Transferable, Revocable,and Suspendable) <br /> f ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> R ApplicatiRn is here made to rry on business in the jurisdictional area of the San Joaquin L cal Health Distri t <br /> y Business Name (DBA) t �- �^r PP–tq- ter Address A�0 1.,�S+e <br /> i Owner ~� Address <br /> k Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �G�' d L �� Emergency Telephone No. <br /> Contractor Licence No. 3177333 1 <br /> t L Applicants Name (Print) - I Title Date <br /> F Please check Applicable Category(1-7)and Fill in the Required Information - <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) `J <br /> For July 1, June 30, 19 Disposal Sites \ <br /> Description(Make/Yr., Color) ' <br /> Serial No. CAL. License No. CAL. License Renewal No, 111 <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 /> M 3. ❑ PERCOLATION TEST 01 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT >,� <br /> i Job Address/L cation O --Gv< .e. d9' ►? f E ' <br /> QX <br /> Owner e_. Address -e - O <br /> t ASEPTIC TANK ❑ CESSPOOL LEACHING FIELD L'SEEPAGE PIT 0 PACKAGE PLANT N_ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR g ❑ OTHER. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ` <br /> Type Construction t `Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) e <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location w <br /> Plant Capacity No. Units Served <br /> 7. 11-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 /> 3 <br /> r 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 r les and reg lations vxnSan Jo uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January'l &-Received.By"January 31� ❑ July 1 &Received By July 31 <br /> IBILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> y �= <br /> FEE . <br /> LESS <br /> PRORAT$ON <br /> PLUS <br /> PENALTY <br /> ;Received <br /> HER <br /> HER <br /> i ate Re i t o, Permit No Issua ce0mall—ed —beliveredAPPLI ANT=RETURN ALL COPIES TO.. ENVIRONMENTAL HEALTH PEAMITlSERVICES -1601 E.HAZELTON . ov 2609 STOCK70N,CA 95201- - <br /> IIItt3 <br />