Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTneAppucauon. } <br /> APPLICATION , <br /> rw 1O (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> (� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ii4he y made to car on usiness in t jurisdictional area oft San Joaquin L cal Health District <br /> Address '� <br /> Or G Business Name (DBA) ti <br /> z Owner Address <br /> a I <br /> :,Firm Partners, Addresses and T lephone Numbers t <br /> aBusiness Telephone No. 6� Emergency Telephone No. j <br /> Contractor Licence No. <br /> Applicants Name (Print)_�Tv>:� ( K.r Title .. r — Date j <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 <br /> Description(Make/Yr., Color) <br /> CAL. Lic <br /> Serial No. CAL. License No. Ise Renewal No. <br /> I <br /> Capacity Gal., Weights &Measures No. <br /> P Y <br /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.,of-Vehicles Stored <br /> f _No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST s - <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> 4i;= <br /> Job Address/Location <br /> Owner • WAj.V_%.A`aQnj Address <br /> j ❑ SEPTIC TANK ❑ CESSPOOL E( LEACHING FIELD 19 SEEPAGE PIT ❑ PACKAGE PLANT <br /> I$i PERMANENT ❑ TEMPORARY ❑ NEW 1(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 /> r � <br /> Plant Location 4 <br /> Units <br /> Plant Capacity No. ns Served <br /> E 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 r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> kordinances, state laws, and rules and r atio o t San Joaquin Local Health District. <br /> R APPLICANT'S SIGNATURE X <br /> 3 <br /> FOR DEPARTMENT USE ONLY y <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 /> - BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED �u1 C AMOUNT <br /> K. <br /> FEE _ $ l S <br /> LESS <br /> PRORATION <br /> PLUS , <br /> PENALTY ' <br /> OTHER 77, <br /> OTHER ] 9 t <br /> Received by Date Receipt No. Permit No. I suanCe D Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A .,P.O.Boa 20D9 $TOCKTON,CA 95201 <br />