Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> 'I <br /> R. ,. APPLICATION } <br /> (For Non-Transferable, Revocable,and Suspendable) �A ' <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> _ Application is ereby made to carr on bust ess in the jurisdional area of the San Joaquin Local Health District <br /> Business Name DBA) Address Q 6W 77 7 . <br /> z Owner .. Address - <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbe <br /> m Business Telephone No. .S >Q 5 Emergency Telephone No. <br /> a Contractor Licence No. ' <br /> LApplicants Name (Print) Title Date <br /> 0 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For'Jtily'1,' ` `"'Jinni 30,^19 Disposal Sites <br /> Desc6p1ion(Make/Yr'I.Co(ar), 5^* 1 <br /> Serial No. _ CAL.. License No. CAL. License Rencwal No. <br /> Capacity A`r=x ` ` x°� Gal., Weights &Measures No, a <br /> Equ�Srr�e.rR'P�Lking•{±�ress ��'- £� � <br /> 2. ❑ PU'MPER YARD c <br /> For July 1, June 30, 19 .; <br /> No. of Vehicles Stored ; <br /> No. of Chemical Toilets Stored ,:- <br /> s.i <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.Q.E. Name R.S. or R.C.E. No. <br /> Test <br /> .,,Lo�tion3 Test Date/Time <br /> 4. � SANITATION PERMIT <br /> Joh Address/1- c tion <br /> OwnerAddress <br /> ❑,SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ P#[� MANENT © TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type'.Construction Di`pxosal Site 5 <br /> Noa,of Units Equipment Sfarag'e/�,Paning Locati6N ) <br /> 6. 0,;PjCKAGE TREATMENT PLANT For July 1, -June 30,'qJ9 j <br /> Operator Name _ _ + Where Certified <br /> Plant'Location t <br /> Pla ._dapacity '' No. Units Served <br /> 7. P,fAUNDRY For-July 1, -June 30, 19 a �'+ <br /> SIZE:° f ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft, ' . <br /> ❑ Df Y CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> ° I hereby certify that I have prepared this application and that the-work will be done in accordance itK Sari Joaquin County <br /> ordinances, state laws, and rules anjlregulationsL44,he San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> 4 FOR DEPARTMENT USE ONLY <br /> Fee Is-Due: ❑ ANNUALLY Q PER UNIT El PER SITE 13 EACH IQ`Ja ary 1 AeivedJanuary 31 ❑ July 1 &Received By July 31 <br /> _ - REMIT <br /> BASE EXPLANATION BILLING REMITTAN $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> L <br /> FEE4' �� 045`I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTTER <br /> OTAFR <br /> Received by Date Receipt No. Permit No. c Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HA ELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 <br /> Mf <br />