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 is hereby made to carry on business in the jurisdictional area of the San oaquin Local Health Di tric <br /> F Business Narr (DBA) Address <br /> k dx Owner N Address <br /> I a.Firm Partners, Addresses and Telephone Numbers <br /> I a Business Telephone No. _ F ,p�/�S Emergency Telephone No. <br /> di <br /> Contractor Licence No. <br /> i I <br /> L Applicants Name (Print) Title Date__�— Z J��X_— <br /> Please check Applicable Category (1-7)and Fill In the Require Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> I <br /> 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 LLttion Test Date/Time <br /> 4. u SANITATION PERMIT <br /> Job Addres / ocation �F R41L t L I I--IV <br /> TS <br /> ,O�,ww Address �J 7/4I <br /> M SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 2 E PAGE PIT; ❑ PACKAGE LANT <br /> 11 PERMANENT ❑ TEMPORARY NEW 2000 REPAIR ❑ OT <br /> H Rh <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 *H <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> t <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 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules d regulations of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ," r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT C1 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT ` <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' M <br /> OTHER <br /> Received by Date Receipt No. Permit No. IssuanC 4 <br /> Date Mailed ' <br /> Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - -1601 E.HAZELTON AVE.,P.O.aox 2009 STOCKTON,CA 9520 <br /> - _--__d 1.. -� i <br />