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 /> ApplicafionA.her made o carry on b siness in the juri dictional area of the yri Joaquin Local Health Di 'ct <br /> ,F Business N me (DBA of 14(z c[_ Address 'a f p G <br /> a Owner Address <br /> Firm Partners, Addresses and Tele h' a Numbers <br /> CL <br /> Business Telephone No. 3 t S Emergency Telephone No. <br /> Contractor Licence No. 3 ' Z ------------------------------- <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Require Information C <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites l k <br /> Description(Make/Yr., Color) i Q <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 <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 Addres Location �,.[ _ ti <br /> t Owner Address ��� U <br /> d C" <br /> ❑ SEPTIC TANK Y1 CESSPOOL "❑ LEACHING FIELD ❑ T ❑ PAC AGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW UPFTtIPAIR ❑ 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 <br /> ` 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> f SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> M <br /> E <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 e S Joaquin Local Health District. <br /> k APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PFR UNIT •PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $DATE DATE REMITTED AMOUNT DUE CHECKED <br /> F <br /> FEE AMOUNT <br /> Ii -�'�"�- <br /> LESS w <br /> PRORATION ,r <br /> PLUS 0 <br /> PENALTY <br /> r <br /> F OTHER <br /> OTHER <br /> a <br /> goI" <br /> Received by Date Receipt No. Permit No. Issuance Dat Mailed Delivered <br /> - APPLICANT—RETURN-ALU-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES— _ 1661 E.;HAZELTON II .O.Box 2009 STOCKTON,CA 45201 � <br />