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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio h eby ma to caqw on business in the jurisdictional area of the San Joaquin Local ealth istr t <br /> �;Business N me (DBA) Address Q 47 <br /> z Owner Address <br /> a <br /> J.Firm Partners, Addresses and Tel/phone Numbers <br /> aBusiness Telephone No. ' CG.S - J a/ Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title — r Date��-f6 .. S-d <br /> Please check Applicable Category (1-7) and Fill in the Required Information I <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. Liccnse 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 Location Test Date/Time 1 <br /> 4. F SANITATION PERMIT O��� 00 <br /> Job Addres Location 01 <br /> Owner Address Z <br /> SEPTIC TANK ❑ CESS OL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE;PLANT <br /> PERMANENT ❑ TEMPORARY 1W NEW ❑ 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 d <br /> Plant Capacity No. Units Served <br /> 7. C1LAUNDRY 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 <br /> II <br /> - I <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, a rules d regulations of San aquih 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t <br /> 7-30-510 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT%SERVICES 1601 E:HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />