Laserfiche WebLink
ApplicationsWill Be Processed when buomwea vropeny ,<.omplelcu. ee Oulu IV Oqj.. <br /> .!/f �,.,,•U�,, , <br /> APPLICATION .ya <br /> .a (For Nan-Translerable Revocable,and Suspendabl SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t1QUM WASTE <br /> Application is hereby ade to carry an business in the jur'sd- ional area of the San Joaquin ocal H alth District <br /> C7 Business Name (DBA) ddress <br /> aOwne Address <br /> firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. C4 Emergency TelephoneNo- n^ <br /> Contractor Licence No. <br /> Applicants Name (Print} Title Date <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 Disposal Sites <br /> Description(Make/Yr.. Calor) <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 /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY VNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July.1_ June 30, 19 <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 /> I hereby certify h have prepared this application and that the work will be done.lnaccordance with San Joaquin County <br /> ordinances, state law d rul sand f� ulations o he Sa oa urn Local Health District. <br /> APPLICANT'S SIGNATURE ~ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT :0 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> ailBILLING REMITTANCE $ 'AMOUNT DUE CHECKED <br /> BASE EXPLANATION _ DATE DATE REMITTED <br /> AMOUNT <br /> 'P <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M <br /> Received by Date Receipt No. Permit No. - Issuance Dam Mailed Delivered <br /> APPLICANT—RETU N ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />