Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION y <br /> : . (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl icatio,�i �h�reby de to carry on usln ss' the jurisdictional area of the Sa Joaqui Local Health Distri t <br /> rn Business a (DBA) a. Addresses. o Q �. <br /> I z Owner fF F_ Add ss 7 <br /> f <br /> U Firm'Partners, Addresses and Telephone Numbers tE MAE <br /> aBusiness Telephone No. 3 Emergency Telephone No. <br /> Contactor Licence No. <br /> L Applicants Name (Print) _R<ck- $�T� � Title �Q) A-#— Date Z . <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑D PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i 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 /> Na. of Chemical Toilets Stored <br /> 3. El PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> tr <br /> Test Location Test Date/Time <br /> 4. 01�SANITATION PERMIT , 3 <br /> Job Address/Location • l jo owso <br /> Owner L .0 u' <br /> Address -5 147)1--*- <br /> 11 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Q SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW WREPAIR ❑ OTHER <br /> 5. I] CHEMICAL TOILETS For July 1, -June 30, 19 .. <br /> Type Construction Disposal Site <br /> ! <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 /> Pla4Capacity No. Units Served I <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE4 ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> t <br /> i <br /> i I hereby certify that I have preuriq this app licati and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru;afvH regulations t S Joaquin Local Health District. <br /> s <br /> APPLICANT'S SIGNATURE X ! <br /> FOR DEPARTMENT USE ONLY { <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNITPER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> $ j <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE G I <br /> LESS <br /> PRORATION <br /> I <br /> PLUS al <br /> PENALTY <br /> OTHER <br /> OTHER <br /> III Received by Date Receipt No. Permit No Issuance Date Mailed ffeliverell <br /> - �� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �� 1601 E. ;ELTO 'V�;�.Elox 2009 . STO�O�95201 j <br />