Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheAppucanon. <br /> APPLICATION <br /> - (For Non-Transferable, Revocable,-and Suspendable) SEPTAGE I I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE d <br /> Applica ' is here made to carry on mess in the jurisdictional area of the San Joaquin�ocal Health trio . <br /> rn Business Name (DBA) D ��UIC� Address <br /> z Owner Address <br /> 4 <br /> 9 Firm Partners, Addresses and Telephone Numbers I <br /> IL <br /> Business Telephone No. mar° 1 6_, Emergency Telephone No. rContractor Licence No. Date`�'���7,F <br /> Applicants Name'{Print)'��"'» � P Title <br /> Please %6 al(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER.�VEHICL-E PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal For July 1, June 30 30,, 1 19 Sites <br /> Description(Make/Yr., Color) ~k, <br /> Serial No. <br /> CAL..License.No.�— ____ CAL._License Ren +xal No. r <br /> Capacity Gal-,Weights & Measures No. ` <br /> i 1 <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 � c <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored „F <br /> 3. 11 PERCOLATION TEST � <br /> �. <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time p <br /> `� o <br /> 4. 'W SANITATION PERMIT <br /> Job Address/Location D <br /> Address `gip G <br /> Owner 11 PACKAGE PLANT C <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD 11 SEEPAGE PIT OTHER <br /> PERMANENT 1:1 TEMPORARY 13 NEW El REPAIR <br /> 5. ❑ CHEMICAL TOILETSFor,,July 1, -June 30, 19 <br /> Type Construction % Disposal Site "--ate-+ <br /> No. of Units <br /> #: Equipment StorageZICleaning�cation{s) x. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 49 <br /> . , Where Certified <br /> Operator Name ,.•tE I <br /> Plant Location <br /> Plant Capacity <br /> No. Units Served <br /> 7. 13LAUNDRY For July 1, -June 3011:9' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑',More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t i <br /> I hereby certif r pared'thl's.ap�Hcation and that the work will;be done in accordance with San Joaquin County <br /> ordinances, late law IeS(and reg la ns�of th Sar Joaquin Local Health District. 5 <br /> I APPLICANT'S SIGNATURE X � <br /> FOR DEPARTMENT_USE ONLY •i <br /> 'Fee IS Due: 11 ANNUALLY .. ❑ PER UNIT - PER SITE 17.1 EACH,, C-1 January &Received By January 31 ❑ July 1 8 ReceivedREMIT 37 <br /> i, BILLING REMITTANCE $ ; AMOUNT DUE CHECKED <br /> . BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> f FEE <br /> LESS - <br /> PRORATION __ ` <br /> r PLUS t I� <br /> k PENALTY <br /> OTHER <br /> OTHER <br /> -1 C>3 1 1 t <br /> Received byy��g <br /> Date Receipt No. Permit No. Issuanc Date Mailed a Iver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES , s_ 1601 E:.FIAZfLTON AVE­AYEP.O.�// J09_ STOCK ON,CA 95201 <br /> til �V' \ iN. 143> 3 .. tra.Y�' l,.1<.'4! - l? _.:. .- <br />