Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transfergbie, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT.. SEPTAGE <br /> LIQUID WASTE <br /> Applicatio hsreb m de to carry orgusi in the jur' Ictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> aOwner Address <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Lf Emergency Telephone No. <br /> Contractor Licence No. 7 <br /> L Applicants Name(Print) ^� ��R6' Title Date <br /> Please check Applicable Category (1-7) and F I I I in the Required Intormatton <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) �ff33 <br /> Serial No. CAL. License No. CAL. Licc nae Renewal No. �V <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address J <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 11 SANITATION PERMITS <br /> Job Address Location S ��1 �i::t� /ft'ug <br /> Owner S Fkee -1 A Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 D (� <br /> Type Construction Disposal Site R� �w In <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 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 0-DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X I <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t <br /> t <br /> 111 <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.H,Z,LTeON.AVE.,P.O.Box 2009- STOCKTON;CA 95201 <br />