Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. J <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE r <br /> s <br /> Applicatio is hpreb ad to c o busi ss in the jurisdictional area of the n Joa in Local Health gstrlct <br /> FB N e�(DB Address 'Q J ele. <br /> ` a Owner lA Address -1 !/ a � <br /> Firm Partners, Addresses and Telephone Numbers c Ck/ ar4f <br /> 14, <br /> Business Telephone No. '3 Emergency Telephone No. <br /> Contractor Licence No. Q f <br /> L Applicants Name (Print) TtIe <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> t 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 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 /> T <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. V <br /> Test Location Test Date/Time <br /> Ilf 4. 11 SANITATION PERMIT <br /> Job Address/ cation 7 s ('rJ GYM <br /> Owner Address <br /> iE "S <br /> 'SEPTIC TANK ❑ CESSPOOL t LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT . <br /> 13PERMANENT ❑ TEMPORARY I NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, :June 30, 19 <br /> a <br /> i Type Construction i 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 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. a <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. __x <br /> _ I <br /> I hereby certify that I have prepared applicatio d th the work will be done in accordance with San Joaquin County j <br /> ordinances, state laws, and rules} gUlations of e n aquin Local Health District. i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT WPFR SITE ❑ EACH ❑.January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED y <br /> AMOUNT dA <br /> FEE <br /> LESS <br /> PRORATION k <br /> PLUS <br /> PENALTY <br /> OTHER x <br /> OTHER <br /> O f <br /> Received by Date Receipt No. Permit o. Issuance Date Mailed De Ivere <br /> .APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 2 1 <br />