Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is by Rade to c rry on busin in the j digonal area of the Sari Joaquin Local Health District <br /> s. , Address -4-767 <br /> w Business Name(DB <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> ' <br /> 00' Business Telephone No. �� d S - Emergency Telephone No. <br /> I -j Contractor Licence No. Z�' <br /> t a Title Date Z 1 <br /> M L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill In the Required Infor anon <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.C.E. No. <br /> Tests Lotion Test Date/Time <br /> M <br /> F 4. SANITATION PERMIT r� <br /> Job Address/Loc ' n <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 5 PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 13 �REPNEW IAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _.0 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,040 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> L <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, and rul and regulaati�ionXZ�-4-- <br /> quin Local Health District, <br /> APPLICANT'S SIGNATURE X "� <br /> N <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due:❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Rec ed By January 3 -JWy 1 &Received By July 31 <br /> IV REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE E IT AMOUNT <br /> r 6 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> j311 <br /> Received by Date Receipt NO. Permit No. Issu cLr Dae Mailed Of iv <br /> efecit <br /> r - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601'E.-HAZ LTON AVE.,P.O.Box 2009 . STOCKTON,CA 95201 <br />