Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferabie, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl icatio is hereby ade to carry on u ess in the jurisdictional area of th San Joaquin focal Health District <br /> N Business Name (DBA) 1 �f Address <br /> z Owner <br /> a Address <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> + 0. <br /> a. Business Telephone No. G Emergency Telephone No, <br /> Contractor Licence No. 3 <br /> Applicants Name (Print) 4wo CICS Title . Date <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 /> ., <br /> Serial No. CAL. License No, <br /> 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 /> 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. l9 SANITATION PERMIT <br /> Job Address/Location �-y <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ;9 NEW 10 REPAIR ❑ OTHER ! <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 016 <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 <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 <br /> I hereby certify that I have prepIred this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules Ind regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X y <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNI ❑ PER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> I DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT F <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> F <br /> OTHER <br /> r <br /> OTHER <br /> V -V" !, If <br /> Received by Date M1' Receipt No. Permit No. Issuance Date Mailed - Delivered <br /> L <br /> '-APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16D1 E.HAZF,LTO/�I AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br /> % �/ IUf <br />