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 /> Application ieo <br /> )tea de to car n b ne in the jurisdictional are of the S n oarLo Health I trict <br /> Business N e (DBA) Address � ��� tA <br /> 4 Owner C. Address g <br /> Firm Partners, Addresses and Telephone Number <br /> a Business Telephone No. ` _ Emergency Telephone No. <br /> � <br /> Contractor Licence No. Xf _ <br /> Applicants Name (Print) Title 15'S' Date j <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July 1, June 30, 19 Disposal Sites L <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. (Td SANITATION PERMIT ,! <br /> Job Address/Location �`''' � -. �'�le <br /> Owner Z Af Address �-O <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD AKSEEPAGE PIT ❑ PACK GE PLANT Q� <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW XREPAIR ❑ OTHER Fes, <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 LJ <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 <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 /> 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 and re lotions the San Joaquin Local Health District. <br /> APPLiCANT'S SIGNATURE X <br /> Qk— <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> 12 DATE DATE REMITTED <br /> AMOUNT <br /> FEE C'k� Q 5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3SL(3 <br /> Received by Date Receipt No, Permit No. f ILSUIIZce Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />