Laserfiche WebLink
r - Applications Will Be Processed When-Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEpTAGE i <br /> ENVIRONMENTAL HEALTH PERMITNt- <br /> LIQUID WASTE <br /> - <br /> Application ' reby made to arty on bu ' ss in e j risd' t' al area of the n Joaquin Local Health Dist�ct "+q <br /> ��t�/ Address i"c ,4- '7G 7 Of c-eC`e <br /> Business Name (D A) <br /> z Owner Address ti <br /> a <br /> Firm Partners, Addresses 2d Telephone Numbers + <br /> a. Business Telephone No. �J Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> Title Date 6V d } <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) i <br /> Serial No. CAL. License No. CAL. Lic.:nse Renewal No. <br /> I <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 1v <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Lo Ion Test Date/Time <br /> r <br /> 4. LR SANITATION PERMIT D5 G �7f _ fly—;I <br /> Job Address/L ation D C4 <br /> Owner Address <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW L- EPAIR ❑ 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 /> f d 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 a regulatiol�of the gJoaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> II 1 <br /> 4 FOR DEPARTMENT USE ONL <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar eived By January 31 ❑ July 1 &Received By July 31 <br /> [� REMIT <br /> BASE EXPLANATION BILLING RATTAN l $ AMOUNT DUE CHECKED <br /> }� DATE A REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> G OTHER <br /> OTHER <br /> Received by Date Receipt Permit No. Issuance Date Mail Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Bo STOCKTON,GA 95201 <br />