Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION <br /> - r.- (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby madeto carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Businesss Name (DBA) � Address _ <br /> Owner `h rote fJIq 91)-5-•TRIoW 2',S-A,.0 — Address 6 2 49 9!�' /-10-5-r 'Tax? PA <br /> y Firm Partners,Addresses and Telephone Numbers <br /> S Business Telephone No. .._ Emergency Telephone No. <br /> 1 �Contractor Licence No. — <br /> Applicants Name (Print) j3-�.E—.- TiUe �'1(,LJ/I�f-R- Date 1A.'1/- 79 <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> ` Description(Make/Yr.,Color) - <br /> Serial No. t �- CAL. License No. CAL.License Renewal No. <br /> 1 Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD t v <br /> For July 1,_ June 30, 19 <br /> I 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 PERMIT / /J y� <br /> Job Address/Location G .� 49 C Lt. ft K•".osh <br /> f <br /> Owner ay..n Ad ess <br /> � <br /> SEPTIC TANK ❑ CESSPOOL 15 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY fig NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-'June 30, 19 <br /> Type Construction Disposer Site <br /> No.of Units Equipment Storage/Cleaning Location(s) - <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> 1 Operator Name Where Certified <br /> Plant Location -- <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. . - <br /> } <br /> 1 hereby certify that l have prepared-this application-and that-fhf workk will be done in accordance with San Joaquin County <br /> (1 ordinances,state laws, and rules end gulations o e San -quinLocar Health District. <br /> APPLICANT'S SIGNATURE Xi 1�----�T <br /> J <br /> i <br /> ' t FOR DEPARTMENT USE ONLY <br /> 1 ( tt�; �' <br /> Fee Is DYe: ANNUALLY ❑ PER UNIT't� {Q PER$ITE . ❑.PI.CH '0 January 1 8 Received By January 31 ❑ July 1 d Received By July 31 <br /> � REMIT <br /> BASE EXPLANATION (—BILLINGREMITTANCE S AMOUNT DUE CHECKED <br /> DATE RATE REMITTED g AMOUNT <br /> l FEE <br /> LESS <br /> PRORATION w..' <br /> PLUS <br /> PENALTY <br /> 4 <br /> OTHER " <br /> OTHER r <br /> ReceiP1 No. Mailed eve <br /> ........,.... ...u....,, .v.amc.n. EHNRnNUPHTAI HPALTH PEAMMMERVICES 4691 E.HAZELTON AVE.,P.O.aas 21109 STOCK N,.CA <br />