Laserfiche WebLink
Applications Will Be Processed.When Submitted Properly Completed. Be Sure To Sig The he Appy ication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable;and Suspendable) SEPTAGE <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE "' <br /> Application ' h made to ca on b 'nes n_the jurisdictional area of the Sat1 Joaquin ocal Ith District d <br /> y Business Na (DBA) Address .l i" <br /> z Owner 92 � . <br /> .; _ Address <br /> zu Firm Partners, Addresses and Telephone NumbersCL <br /> CL f T <br /> Business Telephone No. '• _ f t / Emergency Telephone No. f } <br /> Contractor Licence No. - <br /> LApplicants Name (Print) __ Title, - ; Date <br /> Please check Applicable Category.(1-T)-and Fill,in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR"EACH VEHICLE) ~ hCA <br /> For Jdiy 1, June 30, 19" - r -Disposal Sites <br /> Description(Make/Yr., Color) t <br /> Serial No. CAL. License No. $ x� 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' • t It <br /> No. of Chemical Toilets Stored #v + k <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name ' R.S. or R.C.E. No. <br /> Test L cation .� + r Test Date/Time <br /> 4. SANITATION PERM T�-+ <br /> Job Address/Location <br /> -Owner Address <br /> r ' i <br /> CA<SEPTIC TANK Elj`CESSPOOL ACHING FIELD SEEPAGE PIT—13-PACK-AGE PLANT <br /> 04PERMANENT ❑ TEMPORARY )gNEW ❑ REPAIR ❑ OTHER <br /> 5. ff CHEMICAL TOILETS For July 1; -June 30, 19 <br /> Type Construction "Disposal Site f <br /> I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For JLIIy 1-, -June 30, 19 <br /> Operator Name r Where Certified <br /> Plant Location ` 4 <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 'M1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., C'More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1 <br /> � f <br /> i <br /> • r <br /> y . <br /> I hereby certify that I have prepared thjs p ication d that the work will be done in accordance with San Joaquin County j <br /> ordinances, state laws, arid'rules and Ions oft San Joa n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑_ July 1 &Received By July 31 <br /> REMITTANCE '$ i REMIT <br /> BILLING R ' <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> �y ATE DATE REMITTED - AMOUNT 1 <br /> FEE S -. <br /> LESS <br /> PRORATION <br /> 4 t <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �Mailed <br /> Receivedb �� ��Y Date Receipt No. Permit No. Issu nce Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERM IT/SERVICES1601 E.HAZELTO .,P.O.Box 2009 STOCKTON,CA 95201 <br />