Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 1,7"siness m�e�(p8A Address e <br /> .T1 Owner IYA!L. r 'Q� (SGL Address O P (AI l�- <br /> Firm Partners.Addresses and Telephone Numbers <br /> $ Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) Gs r Title of rdh ry Date <br /> Please check Applicable Category (1-7)ald FBI In nle Required Infor. Son <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites j <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL.License No. .._ CAL-License Renewal No. �. <br /> Capacity Gel.,Weights d Measures No. a <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 0 <br /> For July 1, June 30. 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> kit <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. X <br /> Test Location Teat Date/Time <br /> 4. ❑ SANITATION PERMIT c, <br /> Job Add s/E MbOT 19: �= ,(tee rrL e to*AJ Q - S <br /> OwnerLL IL— �.� � And 2�, r9 INS Lo y1 <br /> Ay13 �n <br /> SEPTIC TANK CESSPOOL AL LEACHING FIELD *SEEPAGE PIT ❑ PACKAGE PLANT <br /> IILPERMANENT ❑ TEMPORARY XNEW ❑ REPAIR ❑ OTHER <br /> 5. O CHEMICAL TOILETS For July 1, -June 30, 19 " <br /> ype Construction Disposal Site _..'"o.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 1 <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 ce"Ity that i h pr pared this applicatio nd that a work will be done in accordance with San Joaquin County <br /> ordinances, state 1 r.'an r a d r gula' of e'Sa NiRlocal Health District. <br /> APPLICANT'S SIGNATURE �- <br /> FOR DEPARTMENT USE ONLY <br /> FN Is DIM:❑ ANNUALLY ❑PEA UNIT WPER SITE ❑ EACH ❑ ja ro ,,I a ReoN By January 31 ❑ July 1 a RecaNea By July 31 <br /> REMIT <br /> BASE EKPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r�r to —'% d I Sig <br /> Yad W DEN ReceilH No. it No. Isellenlee NMii— De <br /> APPLICANT—RETURNE <br /> N ALL COS TO: ENY RONMENTAL HEALTH PEIIMTISERvICES/ hiene./ T JIo-����axis ET "A 1 <br /> owl u"�� <br />