Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Sus, ..jable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat' is hereby mad to carry on bus ness I t juri ictional area of th Jo quin Local Health Distr t <br /> yBusiness-Name (DBA a - Address &� <br /> aOwn l Address00 <br /> J Firm Partners, Addresses and Tele�hoNumbers� <br /> aBusiness Telephone No. —�TG�'�� �i S Emergency Telephone No. <br /> Contractor Licence No. Z c a Z <br /> a Applicants Name (Print)_ Title Date i <br /> Please check Applicable Cate (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30:19 Disposal Sites <br /> Description(Make/Yr., Color) J <br /> Serial Mo. \ 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�Lo�ion Test Date/Time <br /> L7 <br /> 4. SANITATION PERMIT Q y J r <br /> Job Aaes <br /> stocatio 7fOwner AddressSE TANK ❑ CESSPOOL '❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 81REPAIR M"Si +He-"-5"A"e <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction ...--.Disposal Site Z <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� Chefp icals Used/Amount/ <br /> Home owner orltcensed agent's signatum-ertttiesthe following;" celt t in the performance of the work for which this permit is Issued,i shall not employ any person <br /> in such manner as to become subject to txr:rr iP' aom^,ensa!i n lase at Ca item,.).' <br /> Contractor's hiring or srlh-c­ntr rtinf, ,.,a•t:r ,;;;:;,, ific ;oilowing: '"I certify that in the performance of thework for which this permit is issued,I shall <br /> employ persons subject to NoIL,.,u s coa;,,cu aria.,Iawt t;,i Uaiaurnia." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance witli'San Joaquin County <br /> ordinances,.state laws, and r and regula 'ons of he San Joaquin Local Health District. . <br /> APPLICANT'S SIGNATURE X _— _— <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMIT`rED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE L <br /> LESS <br /> PRORATION l <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER— <br /> Received by Date Receipt No. Permit No. lissuande Date Mailed I Delivered <br /> . +ry 11q ^ ,r-I 1 rnp-r T T FNV'-10HM"tT1I HFAI TH PFRMIT­rnvICF4 1F11 F.HA71-1 TON AVF.P 0 r`-?nnn 'TOr"•Tr%N 'A oq?n• _ - <br />