Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. taesure Ioalgn IneHPPucanVrI. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i r y mad�to sin sin the jurisdictional area of the San Joaquin oca Ith Di r' t <br /> Business Na BA) Ad ress <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Te one Nu hers <br /> IL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L4 Title Name (Print) Title -�� Date A <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> L <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 <br /> R.S. or R.C.E. Name - R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ,SANITATION PERMIT { <br /> Job Address/Location <br /> mow" <br /> Owner r Addre <br /> E] SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD EEPAGE PIT ❑ CKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Z NEW A'CLREPA)R `gyp+ OTHE" <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site ` <br /> No. of Units rel 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:.,_ 0_Less,Than 1,000-Sq_Et.,.,., 13 More Than 1,000 Sq.-.Ft. --- <br /> ❑ DRY CLEANING, hemiCals Used/Amount/M `' <br /> o:. ` <br /> Ybmellwreror icarsedagent'ssicgneturecerdfiesthafollowing:"I ccrtiiy,h-;in.V10performanreofthetyarkforwhichthis permitisissued,)sballriot employ anyperson <br /> in such manner-S to beconi9 Subject to L':p'killc�n-5,9mpen5at'13t!iaviJ rri <br /> Contractor's hiring or sub-contacting sigr,ate,re certifies tho following: ..I certify that in the performance of the work"for which this permit is issued,I shall <br /> employ persons subject to workinan's compensattorrtaws o-f�CatifoLnia" r <br /> I hereby certify that I have prepared T ' pplicati nand that the work will be done in,accordance with San Joaquin County <br /> ordinances, state laws, and rules and ulations the S Joaquin Local Health District~` <br /> APPLICANT'S SIGNATURE X <br /> .FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 00 0 <br /> FEE 4 5_� U <br /> LESS <br /> PRORATION <br /> PLUS ^ <br /> PENALTY <br /> ) <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />