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 SEPTAGE <br /> LIQUID WASTE <br /> Applicata n is hereby made to carry on busingss in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) K1 '(aL Address <br /> I`_ Owner AIM Address R 11Fes, S <br /> 110 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. © tV Emergency Telephone No. 1-8(0 7- ( <br /> Contractor Licence No. <br /> L Applicants Name (Print) y- <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 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No, CAL. Liccnse Renewal No. L <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.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location r <br /> Owner Address 'r <br /> ❑-SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANTax- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER r the <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -Y^�'� � .�.p f�.�� f� <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6.-r ❑ 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 /> 7 <br /> j <br /> F <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 rul s and regulations of the San Joaquin Local.Health Distric <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTME USE O <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EA GH ❑ ry.1 & eceived By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING CE $ REMIT <br /> AMOUNT DUE CHECKED <br /> DATE ATE EMITTED AMOUNT <br /> FEE e <br /> LESS <br /> PRORATION <br /> l <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed el' ered ,f <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.,P.O.Boy 2009. STOCKTON,C 9520 . h <br /> ��� I <br />