Laserfiche WebLink
Applications Will Be Processed When Sub AnPPLICATIONd Properlyplete e <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is he by ma to ar on iness�n t junsdictionalAadrd eof the 5art,di3�aquin cal Heal istri r <br /> F Business (DBA) , Address �� ��✓✓ <br /> a Owner �c t C 7���>^ e/ - <br /> } Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. ' <br /> aBusiness Telephone No. <br /> Contractor Licence No. Title er),i,. Date <br /> 7.t/ � <br /> i <br /> �Applicants Name (Print) ..clG €l , <br /> Please check Applicable Category (1-7)and Fill�in the Required Informatlon + <br /> k 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (DFOPoEa SHHICLE) <br /> te E <br /> For July 1, June 30, 19 <br /> 1 Description(Make/Yr.,Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. Gal.,Weights & Measures No. <br /> I' Capacity <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 /> I 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> f R.S. or R.C.E. Name Test Date/Time <br /> Test,�Loc tion <br /> 4, LI SANITATION PERMIT/ _ f� <br /> Job Address/ ocation Address -� <br /> Owner GL♦'EACHWG FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 SEPTIC TANK OC, OOL REPAIR ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified r� <br /> Operator Name 1 <br /> Plant Location No. Units Served <br /> ( Plant Capacity <br /> 7. 13 LAUNDRY For July 1, -June 30, 19 <br /> I SIZE: 11 Less Than 1,000 Sq. Ft., [3 More Than 1,000 Sq. Ft. <br /> e ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> lav an Joaquin Local Health District: <br /> red this app� tion and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that l <br /> ordinances, state laws d ru and regula' s th <br /> APPLICANT'S SIGNATUR <br /> s✓ <br /> k <br /> i_ FOR DEPARTMENT USE ONLY <br /> L Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE [I EACH El January 1 &Recei y anuary 31 July 1 &Received By 31 <br /> IT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE MIT7ED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> i <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> OTHER !� <br /> Receipt No- <br /> Issuance Date Y Mailed Delivered <br /> ermit'No. <br /> Received by Date - 1601 E.HAZELTON AVE:,P.O.Boz 2009 STOCKTON,CA 95201 <br /> APPLICANT' RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIt/SERVICES <br />