Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> Q�. ENVIRONMENTAL HEALTH PERMIT <br /> Jr����/ ox-0 LIQUID WASTE <br /> Application Is bb 'made to r_ on us ess in the jurisdictional area of the Sp4paquin Local Health District <br /> wBusiness Nalpe BA) � `� 15i/ Address <br /> aOwner n �1J r� (/G Addressr <br /> Firm Partners, and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) TitleDate <br /> Please check Applicable Category(1-7)and Fill in the Required Information } <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) ► . 1A h 4,Inn 1,V' 4J, <br /> For July 1, June 30, 19 Disposal Sites QS <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 v.. <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 /> Test Location Test Date/Time <br /> 4.,OKUNITATION PERMIT / C.0'1 r1 0.101— `� <br /> Job Address/Loc�at' n Lsi -- 4 LLL <br /> kV-SEPTIC <br /> 11Bes <br /> Owner �4 Gym/" Address " <br /> !V-6EPTIC TANK CESSPOOL <br /> LEACHING FIELD +SEEPAGE PIT ❑ PACKAGE PLANT <br /> O-RERMANENT ❑ TEMPORARY ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared)l' applicati and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules a re lations he San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1&Received By July 31 - <br /> ILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT ATE DATE REMITTED DUE CHECKED <br /> t LLL���� <br /> FEE <br /> 5`sAMOUNT� <br /> LESS <br /> PRORATION l <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER _ <br /> Received by Date Receipt No. Permit No. IssuancelDate Mailed Delivered <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />