Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION Ili ' <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _ IQUID WASTE <br /> Applicatia by ade rry I ess i e_jurisdictional area of the San Joaquin L al Hea h D' ri <br /> r Business me (DBA) r Addy i <br /> z Owner Address p <br /> a <br /> Firm Partners, Addresses and Tele h n_Numbers i <br /> a Business Telephone No, <br /> �� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the R ulred 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 - 1' <br /> I <br /> No. of Chemical Toilets Stored _ <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name i <br /> Test Location Test Date/Time - <br /> A. JWSANITATION PERMIT <br />= Job Addr s/Location - <br /> Owner Address y f <br /> ElSEPTIC TA ❑ CESSPOOL LEACHING FIELD 11SEEPAGE PIT-0 ACKAGE PLANT <br /> 9PERMANENT ❑ TEMPORARY 13.NEW— REPAIR ❑ OTHER r <br /> 5. ❑ CHEMICAL TOILETS` For Julyy1:,June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units l 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 <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 hav pared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a s and re ulaf ons of th an Joaquin Local Health District. <br /> � S <br /> APPLICANT'S SIGNATURE X <br /> I <br /> 4r FOR DEPARTMENT USE ONLY <br /> 6 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 $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i <br /> FEE yV <br /> • LESS <br /> PRORATION ..r _. <br /> PLUS <br /> PENALTY I <br /> OTHER <br /> 7` <br /> + J <br /> OTHER <br /> 060-�; s 71j <br /> Received by Date Receipt No. Permit No. issuSnce bate Mailed elivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA <br /> - <br />