Laserfiche WebLink
Applications Will,Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r V - APPLICATION <br /> (For Non-Transferable, Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE - f 2C(,'"0 <br /> Application i e eb made t c ry on usiness in the jurisdictional area of the n JoaquiDd ocal Heal h Distri I <br /> NBusiness Na (D A} Address d• <br /> z Owners Address O <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. � Emergency Telephone No. �— <br /> Contractor Licence No. <br /> Date <br /> Applicants Name (Print) Title .� _ <br /> Please check Applicable Category(1-7)-and Fill in the Required Information .4& <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 /> Z. ❑ 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 N <br /> 4. ❑ SANITATION PER (} f -J- M <br /> Job Address/Location t U L. <br /> . 1` <br /> Owner q Address �1__.�,AAt `^* <br /> SEPTIC TAN ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT' /+�a•s l,c (u � <br /> ( PERMANENT ❑ TEMPORARY NEW 0 REPAIR ❑ OTHER �O <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19f of <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 i�lr <br /> w.3 <br /> Plant Location <br /> PIanUC <br /> tiapacity <br /> �• No. Units Served '' " F <br /> 7=„�0'LAUNDRY For July 1, -June 30, 19 ” Y <br /> SIZE: ElLess Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,'Chemicals Used/Amount/Mo. <br /> I hereby c'4tify that I have prepared this application and that the work will be done in accordance,with San Joaquin County <br /> ordinances, state laws, an rules and re Mations a San Joaquin Local Health District. <br /> APPLICANT'S SIGN_ATURE 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 /> REMIT <br /> BILLING 'REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE L�- A/ �� o <br /> LESS <br /> PRORATION <br /> PLUS S <br /> PENALTY <br /> OTHER " <br /> OTHER <br /> 103-21 <br /> } 3 f <br /> Received by Date - .Receipt No. Permit No I suan a Date Mailed D livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 rt iE <br />