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 /> Application i!!,Oreby made to carry on business in t e jurisdi tional area of the San Joaquin Local Health Distric — , <br /> F Business Name (D ) 0 <br /> Address___sw��. 7G7 t <br /> Owner Address <br /> J Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. r <br /> Contractor Licence No. Z..Z <br /> L Applicants Name(Print) C Title Date <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 — 7•a <br /> Description(Make/Yr., Color) <br /> Serial No. CAL.License No. CAL.Lfcznse Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,_ . June 30, 19 <br /> F <br /> _\ I` <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 PERMIT ? <br /> Job Address/Locatio <br /> 2- <br /> "�� ) 60 \N <br /> Owner Address <br /> ❑ SEPTIC TANK 10:1CESSPO L �OKLCHING FIELD T ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 1 t <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 .•11 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. _ <br /> 7 <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 rules andguI tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ,es <br /> i <br /> A <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:O ANNUALLY ❑ PER UNIT 'PER SITE ❑ EACH u <br /> . January 1 8 RecerveC By January 31. 13 July 1 3 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION A <br /> � DATE DATE REMITTED MOUNT DUE CHECKED <br /> FEE ) AMOUNT <br /> t IVY <br /> LESS <br /> PRORATION I� <br /> PLUS = <br /> PENALTY t j <br /> OTHER + <br /> OTHER j <br /> e02 n <br /> f. f / �J�{t <br /> Recrived by Date — 09-01 <br /> ta `f ( / — <br /> ReceiPt Permit No. I suan Date Mailed De ivere0 i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SE—RVIICESS 7801 E;HA1ZELTON/AVE.,A.O'./Bow 2006 .STOCKY ,CA 95201 <br />