Laserfiche WebLink
Applications Will Be Processed When Submitted Properly omp e <br /> APPLICATION <br />��%=x-- •": (For Non-Transterable, Revocable,and Suspendabie) <br /> SEPTAGE <br /> ENVIRONMENTAL 14ATE TH PERMIT <br /> LIQUID <br /> i <br /> of T I <br /> Application is hereby made to carry bus iness in the jurisdictionaAa�ressthe San Joaquin Local Health District <br /> Business Name (DBA) 4 Addressr <br /> aOwner l J } <br /> Firm Partners, Addresses and Telephoneer Emergency Telephone No. <br /> aBusiness Telephone No. ®y <br /> Contractor Licence No. Title Date <br /> L Applicants Name (Print) <br /> Title ) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> �, ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) j <br /> For July 1, <br /> June 30, 19 Disposal Sites i <br /> Description(Make/Yr., Color) T _ - CAL.'License Renewal No. <br /> CAL. License No. <br /> Serial No. <br /> i Capacity Gall._Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD .. <br /> I For July 1, June 30, 19 <br /> No. of Vehicles Stored - y - <br /> No. of Chemical Toilets Stored <br /> t 3. ❑ PERCOLATION TEST r` R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time W <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ` Address <br /> Own PACKAGE PLANT V <br /> SEPTIC TANK ❑'CESSPOOL_ LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> ❑ TEMPORARY '❑ NEW 1L ❑ REPAIR <br /> ❑ PERMANENT "` - r7•, i <br /> 5. ❑ CHEMICAL TOILETS For July ' -JuneR30, 19 <br /> ',. Type Construction Disposal'Site <br /> No. of Units Equipment Storage/Cleaning Location(s) Y <br /> 4 i <br /> g_ ❑ PACKAGE TREATMENT PLANT For-`July 1', -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location `ti No. Units Served <br /> Plant Capacity , <br /> 7. ❑ LAUNDRY For July 1, -June <br /> k ❑ Less Than 1,D00 Sq:Ft., ❑ More Than 1,000 Sq Ftp + <br /> SIZE. � f <br /> ❑ DRY CLEANING, Chemicals Used/Arilount/Mo ;.1 <br /> 4 - <br /> l hereby certify that I have prepared this applic tla on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re late f the San Joaquin Local Health District. <br /> t <br /> l <br /> APPLICANT'S SIGNATURE XL <br /> FOR DEPARTMENT USE ONLY <br /> REMIT <br /> P Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ .July 1 &Received <br /> CH CHECKED <br /> July <br /> 34 <br /> ' REMITTANCE AMOUNT DUE <br /> BILLING REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE -`" <br /> FEE <br /> I LESS <br /> PRORATION - <br /> I PLUS <br /> PENALTY <br /> ! OTHER <br /> I' OTHER <br /> O (} Mailed Delivered <br /> Date Receipt <br /> No <br /> ;Permit No. Issuance ate <br /> Received by-� 1601 E.HAZELTON AYE..P.O.Box 2609 STOCKTON,CA 4520 �- <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES LA7_,� <br />