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 <br /> EPTAGE <br /> LIQUID WASTE �. <br /> Application Is reby m,gde car n mess In the jurisdictional area of th quln Local H Ith <br /> Local <br /> NBusiness Name (DBA) � �!� Address �—� � <br /> z Owner Address <br /> C <br /> Firm Partners, Addresses and T le h ne mbers <br /> n. Business Telephone No. Q Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) < Title a Date ; <br /> Please check Applicable Category (1-7) and Fill in the Required Information 4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Sites <br /> Disposal For July 1, June 30, 1'3 N ' <br /> Description(Make/Yr., Color) VV <br /> t 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 /> r. <br /> 3. ❑ PERCOLATION TEST <br /> I R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> TesettLL cation Test Date/Time <br /> 4. ¢SANITATION PER IT <br /> Job Address/L catio <br /> Owner Address <br /> 13 SEPTIC TANK EI CESSPOOL 1XLEACHING FIELD {�SEEPAGE PIT 13 PACKAGE PLANT O <br /> t� <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW *REPAIR ❑ OTHER G} <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site_ fn <br /> No. 6f Units Equipment Storage/Cleaning Location(s) <br /> i 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 (� <br /> i Operator Name Where Certified <br /> Plant Location <br /> is Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ElLess 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 with San.Joaquin County <br /> ordinances, state laws, and r les and reg tions'o San a uin.Local Health District. <br /> c <br /> i <br /> APPLICANT'S SIGNATURE X <br /> I 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 /> BASE EXPLANATION BILLING R ITTANCE $ AMOUNT DUE CHECKED <br /> ED AMOUNT DATE DATE- REMITTED <br /> a y5 <br /> FEE J <br /> LESS <br /> 9 PRORATION - <br /> PLUS <br /> 'PENALTY - <br /> F OTHER <br /> 4 r <br /> 4 OTHER <br /> x p 1. a 1a-ay� draw <br /> Received by Date Receipt No. Permit No lissuafice Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZE TON AVE_ .O.Box 2009 STOCKTON,CA 95201 <br />