Laserfiche WebLink
f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> APPLICATION <br /> i (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE �s <br /> LIQUID WASTE <br /> Application is he eby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) rA—" Address <br /> z Owner <br /> < � Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print} Title <br /> Date <br /> Please check Applicable Categoryr r.:'"P+� r,�Mr r c = :rn <br /> PP (1-7) and Fill in the Required Information :�t:,g.,�� i_, ;,v �; �,_L�, <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE 2�W Rrn <br /> j ) C211if. �w05 <br /> I For July 1, June 30, 19 Disposal Sites Ply.Ar.Q Cdil[ILG i,'C f"167173 <br /> i' <br /> Description(Make/Yr., Color) � <br /> Serial No. CAL. License No, <br /> CAL. Licc-sse Renewal No. <br /> Capacity Gal., Weights &Measures No. a- 9 <br /> i Equipment Parking Address � <br /> 2. ❑ PUMPER YARD .� i <br /> For July 1, June 30, 19 4 <br /> No. of Vehicles Stored- <br /> No. of Chemical Toilets Stored^ <br /> 1 <br /> 3. 1:1 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. r <br /> Test Location Test Date/Time <br /> 4. % SANITATION PERMIT . <br /> Job Address/L ti <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ,'❑ TEMPORARY XNEW- -El-REPAIR f ❑ 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) i <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 t <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 x <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. - ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 hereby certify that 1-have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and �ad gulations of the San Joaquin ocal Health District. <br /> APPLICANT'S SIGNATUREX CL!',. :;r:'j r'r� SEV�CE <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 /> BASE EXPLANATION BILLING REMITTANCE $ 1 REMIT <br /> DATE DATE REMITTED AMOUNT OUE CHECKED <br /> FEE <br /> AMOUNT <br /> `^ ��l <br /> LESS V <br /> PRORATION ��} - <br /> e PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed <br /> Delivered <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SEAVICES 1601 E.HAZELTbN AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />