Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The,Application. <br /> APPLICATION ' <br /> 4z_1 0 (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEATH PERMIT <br /> LIQUID WASTE <br /> Application s hereby made to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA)5X. '�'�1'SN SSof��� =JJC Address CtS2Q <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 44'6.-9(;?e>77 Emergency Telephone No. <br /> Contractor Licence No. — <br /> 'rD12_ Date S"� <br /> Applicants Name(Print) "TA�3��� 'fit� � Title ��1J�A <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites Ai <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 /> Test Loo Ion Test Date/Time <br /> 4. B SANITATION PERMIT <br /> Job Address/Location <e <br /> Owner 5c &_--r0^) Address S& 'S <br /> ❑ SEPTIC TANK ❑ CESSPOOL E3LEACHING FIELD O'SEEPAGE PIT ❑ PACKAGE PLANT <br /> 8-`PERMANENT ❑ TEMPORARY •❑ NEW 2REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Por-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 ne prepared this appii a ' n and that the work will be done in accordance with San Joaquin County <br /> ordinances,state law ules and gulati o he San qui Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januaryt3l ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS -17 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER rl-7 F ,' <br /> v <br /> Received by Date Receipt No. Permit No.' Issdan9b mate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />