Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSure To sign IneAPP111-aLwII. V <br /> APPLICATION �V <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ezpby made to carry on business in the jurisdictional area of the SaJoaquin Local 1'alt District <br /> ,n Business Na a (D A) Address �' l`'� <br /> I.- Owner Address <br /> a - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a, Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No.. . � <br /> Title Date <br /> Applicants Name(Print) <br /> Please check Applicable Category (1-7)and Fill in the Required 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 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addres Lo at' <br /> Owner Addre r.t <br /> © SEPTIC TANK ❑ CESSPOOL EACHING FIELD12�SEEPAGEPIT C1 PACKAGE PLANT V" <br /> 11PERMANENT ❑ TEMPORARY C3 NEW REPAIR 11 OTHER v <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 7� <br /> Type Construction Disposal Site <br /> No. of Unfits Equipment Storage/Cleaning Location(s) <br /> r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1',-June 30, 19 <br /> Operator <br /> .Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 0, 19SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Herneowner orlicensed agentssignature,certifiesthe following:"I certify that in thepef rrnanceof+tetivorkfor�hichthispermitisissued,islsallnotemployanyperson <br /> in such manner as to become subject to worKman's compensation lav+s of rallifOrni t" <br /> Contractor's hiring or sub-contracting sir�natur� cortikes the following: certify that in the performance of the work far which this permit is issued,i shalt <br /> employ persons subject to workman's compensation laws of California." <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, a rules and regulatiansrot the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X C� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUN <br /> FEE <br /> LESS v \ <br /> PRORATIONNt \ _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER f C <br /> �r 3 � '.J <br /> Re eived y ate Receipt No- Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCK70N,CA 85201 <br />