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) i <br /> ' F ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ereby made to carry on business in the iuris ictionai area of the San,,Joaquin Local Health District <br /> H Business Name (DRA) o �� Addrgss�_ 76 7 <br /> z Owner Address <br /> a - <br /> J Firm Partners, Addresses and Telephone Numbers C <br /> aBusiness Telephone No. -36PS10 ff Emergency Telephone No. <br /> Contractor Licence No. <br /> ..L Applicants Name (Print) tj Title Date a- <br /> Please check Applicable Category 6L)and Fill in the Req red Information U 0 <br /> j, 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> r Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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 /> 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'Addr s/Location 5 7 ''Q-1 h <br /> I Ow r 7 Address J j <br /> L�� S�-PTIC TANK ❑ CESSPOOL ,�,�ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT 1, <br /> t L�YPERMANENT ❑ TEMPORARY � NEW ❑ REPAIR 11 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified 1 <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> T. ❑ 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 /> ti I hereby certify that I have prepare this application and that the work will be done in accordance vw{h San Joaquin County <br /> ordinances, state laws, and rule regulati s o e n Joaquin Local Health District. <br /> ARPLICANT'S SIGNATURE X <br /> J� <br /> FOR DEPARTMENT US ONLY <br /> -"' a Is Due: ❑ ANNUALLY © PER UNIT .❑ PER SITE ❑ EACH ❑ Jan ry 1 E, E,�.dEly Jan ry 31 ❑ July 1 B Received By July 31 <br /> REMIT <br /> a' BILLING REMITTANC $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> <s r DATE DATE REMITTED AMOUNT <br /> ' FEE <br /> r <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuanc Date.' Mailed Delivered E <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'FIEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 ; STOCKTON,CA 95201 <br />