Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION S <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE_ <br /> LIQUID WASTE <br /> Application is ere by madetcarry on b iness int ejuris fictional area of the San Joaquin Local Health Distri�c�j j <br /> Business Name BA) .Address (57&711' E 7 <br /> aOwner Address �-- �- <br /> Y Firm Partners,Addresses and Telephone Numbe <br /> Business Telephone No. 3z y` SW 4� Emergency Telephone No. ` <br /> Contractor Licence No. Z <br /> Applicants Name (Print) Title ,211.x7 Date ID <br /> Please check Applicable Category(1-7)and Fill in the RequIrA Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) p:� <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 /> 3. ❑ PERCOLATION TEST ' <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Locati n Z 7 <br /> O,,wJ�r = � v2.✓,,�n��-.c. /7 Address 7 %Z/A/ � !I& 1,rL_3 7 <br /> L7 SEPTIC TANK ❑ CESSPOOL ❑,_,�'EACHING FIELD i SEEPAGE PIT ❑ PACKAGE PLANT G <br /> PERMANENT ❑ TEMPORARY L7 NEW ❑ REPAIR 0 OTHERO*R V0 '7-'CVP <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19- <br /> Type <br /> 0, 19Type Construction Disposal Site I <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 1 <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 /> V <br /> i <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;anndd�9J and regulaf�l��lQQnss of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X `A �L' �1� <br /> FOR DEPARTMENT USE ONLY <br /> I"IS Due: ❑ ANNUALLY ❑ PER UNIT lxPER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> i <br /> Received by Date Receipt No. Permit No. leeuenoa to Mailed Delivered. <br /> l <br /> APPUGANT—RETURN ALL COPIES TO: ' ENVIRONMENTAL HEALTH PERNIT/6ERVICEB:.- 1601 E.NAZELTON AVE.,P.O.Bea 2000 a�TOCI(�TOy/�CA 8301 , <br />