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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appli is hereby male to arry on usin s' theAArisdictional area of th Jo In Local Health Distr' t <br /> yBusine lame (DB r Address <br /> z Own r Addre <br /> a <br /> Firm Partners, Addresses and Telephone tubers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title t c Date <br /> ' Please check Applicable C ory (1-7)and Fill in iWe 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 /> 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 /> 3. ❑ PERCOLATION TEST 3 �} <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. *T PE IT t C <br /> Job Address/Locatio -� <br /> Owner ir Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL FIELD--❑-SEEPAGE-PIT ❑ PACKAGE PLANT <br /> 2'PERMANENT ❑ TEMPORARY ❑ NEW REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units t Equipment Storage/Cleaning Locatidn(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 -a-- � - - - , <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. �- <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4 <br /> +t <br /> -. - - � - - .. . + i - • ��yr - :r -_.' .. . ..:.... <br /> I hereby certify that I have prepared this application and tQ the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules and gul ions of the San Joaquin Local Health District. <br /> f <br /> APPLICANT'S SIGNATURE X <br /> I <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 /> --- <br /> - REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE s <br /> LESS � Jlv <br /> PRORATION VV <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Pe mit No. /issuan?b Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />