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 /> (k� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio ereby mad to carry on All .�s�lnes®s In the jur' di nal area of the San oaquln Local Health District <br /> yBusiness Name (D Address .- ?6 7 <br /> z Owner <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> ILBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date 'mod <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) rf <br /> For July 1, June 30, 19 Disposal Sites b <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. 6 <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT_ \h <br /> Job Address/L cation <br /> Owner Address <br /> C1 SEPTIC TANK E] CESSPOOL 10:1LEAC WING FIELDIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 11NEW 9R REPAIR <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 /> Where Certified <br /> Operator Name G <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 this application and that the work will be done in accordance t San Joaquin County <br /> ordinances, state laws, and rules and regulations of the Sarlr4oaq 'n Local Health District. t <br /> APPLICANT'S SIGNATURE X <br /> z, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re d ey J uary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE EMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> J <br /> OTHER 74 <br /> Received by Date Receipt No. Permit No. Issuance-D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />