Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> i APPLICATION / 5?_ U y <br /> (For Non-Transferable,Revocable,and Suspendable) S PIAGE/� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> UQUID WASTE <br /> Applicatio a e arry on busi a in the jurisdictional area of thee San �l Healt Dis ric <br /> Business Name DBA _ aAddress i1 <br /> zOwner - - _.._ Address _ - <br /> `� Firm Partners. Addresses and Telephone Numbers — <br /> `o Business Telephone No. I - Emergency Telephone No. -� <br /> � Contractor Licence No. 3-0 - <br /> Applicants Name (Print) Title - 'yam Date <br /> - - <br /> Please check Applicable Category (1-7)and FIII in the Requ red Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - <br /> Description(Maker'Yr., Color) __ _- - <br /> Serial No, CAL. License No. CAL.License Renewai 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 /> i R.S. or R.C.E.Name R.S. or R.C.E.No. _ <br /> Test Location - - ___ Test DatelTime -- <br /> 4. ❑ SANITATION PERMIT or <br /> t Job Address/1 oration,$ <br /> wner _ or Address <br /> SEPTiC TANK CESSPOOLJ,, LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARYNEW ❑ REPAIR ❑ OTHER <br /> S. <br /> ❑ CHEMICAL TOILETS For July 1a 30, 19! <br /> Type Construction _ I Disposal SiteNo.of Units ____ _ Equipment Storage/Cleaning Location(s) _---_ -- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19__ _ <br /> Operator Name Where CertifiedlL <br /> Plant Location <br /> t Plant Capacity _ No. Units Served - <br /> 7. f] 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 /> t <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San,Joaquln County <br /> ordinances, state laws, and rules and r�egul_ of the San Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X ---(-�� "' - -- - - - - <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ January' &Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOtlNT""�� <br /> FEE _ <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> - - C <br /> OTHER <br /> OTHER <br /> Recewed by Date Receipt No. - Permit No. I uance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.009 2009 ,�KTOK CA 95201_ <br />