Laserfiche WebLink
Comp e e <br /> Applications Will Be Processed When SuAPPLICATION <br /> • (For Nan-Transferable,Revocable,and Suspendabie) <br /> SEPTAGE <br /> ENVIRONMENQTAo WASTE TH PERMIT <br /> Ll made to carryon business in the j sdictional area of the San Joa1111111 111111quin Local Health District , <br /> A'rlication is hereby Address <br />.n Business Name (DBA) P Address <br /> aOwner <br /> L) Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> COL' Business Telephone No. <br /> Contractor Licence No. Titl <br /> LApplicants Name (Print the Required Information <br /> ---- <br /> Please check Applicable Category (1-7) and Fill in <br /> 1• ❑ puMPER VEHICLE PERMIT REGISTRATION (FOR o ACS a VEHICLE) <br /> For July 1, June 30, 19 <br /> CAL. License Renewal No. <br /> Description(Make/Yr.,Color) CAL, License No. <br /> x <br /> Serial No. <br /> Gal.,Weights & Measures No. a <br /> Capacity <br /> Equipment Parking Address }} <br /> 2, ❑ PUMPER YARD <br /> I <br /> For July 1,_,June 30, 19 <br /> No. of Vehicles Stored <br /> k No. of Chemical Toilets Stored <br /> I 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. 0 SANITATION PERMIT <br /> Job Address/,Location Address <br /> Owner U 13 LEACHING FIELD /n SEEPAGE P1T PACKAGE PLANT <br /> ❑ CESSPOOL ❑ OTHER <br /> TANK El NEW <br /> [I REPAIR <br /> ❑ PERMANENT ❑ TEMPORARY <br /> 5. C] CHEMICAL,TOILETS For July 1,-June 30, 1pispo las Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> f No. of Units <br /> r <br /> g, 11 PACKAGE TREATMENT PLANT For July i, -June 30, 19 Where Certified <br /> Operator Name <br /> i Plant Location No. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1,-June 30,[I More <br /> �1,000 Sq. Ft. <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> E ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> l pion and that the work will be done in accordance with San Joaquin Coun <br /> 1 hereby certify that I have prepared this alty <br /> I <br /> ordinances, state is , and rules and regulation"f the San Joaquin Local Health District. <br /> � APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE-ONLY <br /> July 1 &Received By July 31 <br /> PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ REMIT <br /> Fee is Due- C3 ANNUALLY ❑ PER UNIT $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> k OTHER <br /> OTHER _ ��� f� <br /> 3 ''CJ ! (06 7 ( Mailed 1]elivered <br /> !�. J f � permit No. issuance Date -STOCKTON;GA 95201 �� <br /> Receiv by <br /> ate Receipt No. 1601 E.HAZELTON AVE.,P.O.'Box 2609 <br /> NTAL HEALTH PERMIT/SERVICES <br /> pppLICANT—RETURN ALL COPIES TO: ENVIRONME <br />