Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r APPLICATION <br /> (For Non-Transterable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH_ PERMIT <br /> LIQUID WASTE <br /> Application is hp1gypade to car es in the jurisdictional area.of.the.San Joaquin oval Health DistnC <br /> yBusiness Name DBA) { Address, <br /> aOwner �4 _u Address -_ <br /> J Firm Partners, Addresses and Telephone Numbers a. <br /> aBusiness Telephone No. —�-,z' Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print} Title .�%'� Date &XIA <br /> Please check Applicable Category(1-7)and F I in 1he Requiredintormation,-I, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,' -June 30; 19 -=–:=--Disposal Sites.— <br /> Description <br /> ites.Description(Make/Yr., Color) <br /> Serial No. s CAL. License No. CAL. License Renewal No. <br /> - 9 <br /> Capacity---, Gal., Weights_& Measures No. "^ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 c' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, I] PERCOLATION TEST ; <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ovation Test Date/Time <br /> 4. ANITATION PERMIT-- <br /> Job <br /> ERMIT-Job Address/Locatio � ti e G�g <br /> Owner '�'� - Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> '❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ 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 <br /> Plant Location ) <br /> Plant Capacity No. Units Served Y <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, t ((JJ <br /> " I hereby certify that'l have prepared this application and that the work will be done in accordance with-San Joaquin County <br /> ord1.inances, state laws, and ru and.regulatio of th San Joaquin LoHealth District. <br /> APPLICANT'S SIGNATUREX � —•„ - <br /> 41 <br /> FOR DEPARTMENT. SE ONLY � ` � Lj <br /> i •� <br /> .. Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH... b„,0 January 1 &Received By January 31; '`° ❑,-July 1 &Received By July 31 <br /> r r <br /> REMIT <br /> BILLING REMITTANCE $ - <br /> BASE EXPLANATION _AMOUNT..AMOUNT DUE CHECKED <br /> .. DATE - DATE' REMITTED — _ AMOUNT - <br /> FEE - <br /> r- <br /> LESS k? �. 3, <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> LS Gq <br /> r. Received by Date Receipt No. Permit No Issu nce D e Mailed Delivered; <br /> I APPLICANT-RETURN ALLCOPIESTO: ENVIRONMENTAL`HEALTH PERMIT/SERVICES 1601 .HZELTON AVE.,P.O.Box 2009 STOCKTON,CA'95201 <br />