Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -y. APPLICATION <br /> a (For Non-Transferable,'Revocable, and Suspendable) A <br /> ENVIRONMENTAL HEALTH PERMIT {. SEPTAGE <br /> LIQUID WASTE-­. <br /> Application is he carry On b sin s In the jurisdictional area of tan Joaquin Local_Health District- <br /> y Business Name (DBA) � ddress 0. o �r <br /> a Owner <br /> Address <br /> Firm Partners,Addresses and Telephone Numbers <br /> Ix <br /> Business Telephone No. Emergency Telephone No. <br /> a Contractor Licence No. N : <br /> a 'r w <br /> LApplicants Name (Print) Title <br /> Please check Applicable Category {1 t7)and Fill in the Required Infor.1 1mation , r. Date t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 - - Disposal Sites I, <br /> Description(Make/Yr., Color) <br /> Serial No. �. CAL. License No. !' { <br /> Capacity Gal., Weights & Measures No. CAL. License Renewal No. <br /> - + + <br /> Equipment Parking Address .ter <br /> 2.= ❑ PUMPER YARD <br /> For July 1, s June 30, 19y <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored . <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name f ?' <br /> . R.S. or R.C.E. No. y ;t <br /> T st cation Test Date/Time ti <br /> 4. SANITATION PERMIT_ <br /> � ii <br /> Jo Address/Location Z`L4 b ! t L o6 <br /> 4 Owner <br /> Add❑ SEPTIC TANK C] CESSPOOL ❑ LEACHING FIELD r ss' SEEPAGE PIT ❑ PACKAGE PLANT 8 <br /> PERMANENT ,❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER t <br /> 5. • <br /> CHEMICALTOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> Disposal Site 4 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br />{+ 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Ij <br /> Operator Name Where Certified + <br /> Plant Location i a <br /> Plant Capacity a <br /> No. Units Served <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. <br /> amermannerrticen,e:lnyr-•ntjjecit oturec^r1€e the'..�Le ,iltg:"ir�tfi!yttials�thepe ftrr,a^CeoEJ1e ' a <br /> in such manner a5 to become su'b;ecf to r�trk nail'^e:,111pe:5:liar la1�s rf Califitr�i.t Y' f'' 'SICK '°•�}ermif is sued, shall nfft erupIoy any persc', <br /> Contractor's hiring or sub-crrnt.acting aignata:n certifies 1'11?vfollgwing.- '1 certifythat in the poilolrn,Irc�-et ttie work for which this'pesrnit is issued,I shat) <br /> employ persons stlbiect to workman's comPeFisation laws of califomia <br /> I hereby certify that I ha prepared this application and'that the .o rk will be done in accordance with San Joaquin County ' <br /> ordinances, state laws, s and re tions an _ <br /> r - Lo Health District. f <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER'UNIT}2'h s <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received BTJanuar 31 t <br /> • - �'= y Y I�`July 1 8 Received By July 31 <br /> BAS EXPLANATION BILLING REMITTANCE $ 'f REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED - .{ <br /> AMOUNTS _ <br /> FEE �.. - O <br /> LESS h <br /> PRORATION - <br /> PLUS * s : <br /> PENALTY <br /> N <br /> A OTHER <br /> ry <br /> OTHE9' e, <br /> ° - ;1 � <br /> mac.. a "� .� <br /> Received by <br /> by pate Receipt No. <br /> P Permit No. Issu ce p ailed Delive ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH•PEAMIT/SERVICES t <br /> 1661 E:HAZELTON .O.Box 2009 STOCKTON,CA 95201 <br />