Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION, <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicata s b de to car n buqI�Crr�iess in th jurisdictional area of the S aqui oval Health District <br /> rn Business N�e (DBA)' ( �Ir'Yers Cr1lale` jurisdictional <br /> Address � b <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Nu bers fl <br /> aBusiness Telephone No. �s�y Emergency Telephone No. <br /> Contractor licence No. <br /> L Applicants Name (Print) t _ �Z mi+� ''�G _Title Date 2 717 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> I. ❑ 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. Licc~se 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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ` <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERM T <br /> Job Address/Location ?AI EtiST <br /> Owner AiR G-1 H ry Ifer. Address q;2 01 -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAINT <br /> Iff PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ 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 /> I 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 r les and re latio)f the S�Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 6" <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT IW PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &R eived By July 31 <br /> BI LING REMITTANCE $ REMiT <br /> BASE EXPLANATION HATE REMITTED AMOUNT DUE HECKED <br /> AMOUNT <br /> FEE �S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ? ora <br /> ecewed by I Date f Receipt No. Permit No, I suance Date MailedD vered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 S OCKTO 01 "Z � <br />