Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application:. <br /> APPLICATION <br /> s, (For Non-Transferable, Revocable,xand Suspendable) <br /> 42� <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio ' thereby mad to carry onbusiness in the jurisdictional area of the San Joaquin Local Health District s <br /> HBusiness Name (DBA)��� n Address <br /> a Owner 'lp Address -CY ;�L 7 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. t2 3 <br /> L Applicants Name (Print, `I Y \_AJ , C Title d Date 7011 T <br /> Please check Applicable Category (1-7) and Fill in the Required Information . <br /> 1 <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 ii Gal_, Weights &Measures No. - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,,19 <br /> No. of Vehicles Stored s <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST;, <br /> R.S. or R.C.E. Namel Y R.S. or R.C.E. No. <br /> t , <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 1..' <br /> Job Address/Location � �� 4/J A.� A e- SSi <br /> Owner �� )(� "� Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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 _ ,_ .r, _- _ - =,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. j <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.. i <br /> a <br /> 1 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,'Vojulesanq _egu do of-the SanJoaquinLocal Health District. 3 <br /> AP'PLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> l _ <br /> Fee Is Due: ❑ ANNUALLY ❑'PER UNIT PER SITE ' ❑,~EACH ❑ January'1 B,Re_ce ed B Ja uar 1 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATIONAMOUNT DUE CHECKED "I <br /> e DATE `DATE;- MIT AMOUNT <br /> �^ <br /> _J -- <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I r <br />' PENALTY-; <br /> OTHER 1 <br /> OTHER ' <br /> i i - _ • .n. a '. i. <br /> Received by Date Receipt No. Permit No. Issuance Date MailedDeliver&d, <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON.AVE.,P.O.Box 2009 -.STOC TON;CA4 5201 <br />