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) SEPTAGE; Y/ <br /> ENVIRONMENTAL HEALTH PERMIT 11// <br /> LIQUID WASTE .J <br /> Applica: is h re e to ca on business in the jurisdictional area of the San Joaquin al Hea kh ct <br /> Business ame ( B } Address S <br /> z Owner Address S <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 'a Business Telephone No. Emergency Telephone.No. <br /> Contractor Licence No. <br /> Applicants Name (Print) 8d C Title f Date S �l <br /> Please check Applicable Category(1-7) and Fill in the Require 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, 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 Location Test Date/Time <br /> 4. gSANITATION PERMIT Q (,j,j j <br /> Job Addres Loca ion <br /> Owner Address e <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> �CPERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 0 <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 certify that I h ed this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and! r regulations of t SanjJoaLim Local Health District. <br /> n <br /> APPLICANT'S SIGNATURE X <br /> i <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 /> BASE EXPLANATION BILLING REMITTANCE PUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE yS �S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 14 <br /> OTHER <br /> b <br /> Received by Date Receipt No, Permit No. Issua ce Date Mailed eliver d <br /> APPLICANT—RETURN ALL COPIES TO:" ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009/ ST G TON,CA <br />