Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> > - APPLICATION <br /> { - (For Non-Transterable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> -LIQUID WASTE" <br /> i Application i hereb de to carry n siness in the jurisdictional area of the San Joaquin Local Health District <br /> nBusiness Name (DBA) .. 4 Address , <br /> zz Owner_ Address <br />[ 3 Firm Partners, A d ,;Les' eephone Numbe s <br /> a Business Telephone.No. :. 1 ;. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) STitle Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> P <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />` For July 1,_. .._June 30„1:9 -., c_,-_.Disposal Sites . <br /> Description(Make/Yr., Color) C� <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal:, Weights & Measures No. <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD F <br /> • i . <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. ❑ SANITATION PERMIT ^ <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK VCESSPOOL ❑ LEACHING FIELD t2r,$EEPAGE PITO ❑ PACKAGE PLANTS <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWEPAiR E] OTHER <br /> __�R _ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 3009 od <br /> a <br /> Type Construction Disposal Site /J <br /> No. of Units Equipment Storage/Cleaning Location(s) t ! l <br /> & ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> t 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., 't-❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k <br /> Thereby certify that i have prepared thi -app ation and that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws, angLLuJpA n ulati ns f the San Jo uin Local Health District. / <br /> ,APPLICANT'S SIGNATURE X <br /> - 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 /> BILLING REMITTANCE $ ,, REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> f� DATE DATE REMITTED L�C1A 'AMOUNT <br /> FEE �lV V•.� �. !�✓ �p <br /> LESS <br /> PRORATION - .. . .._r . <br /> PLUS <br /> -- -PENALTY <br /> OTHER <br /> OTHER i <br /> y <br /> Received by Date y Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: �ENVIRONMENTAL-HEALTH PERM ITISERVICES 1601 E.'HAZELTON AVE.,P.Q.Bos 2009 3-STOCKTON,CA 95201 r ... <br />