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) SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> mBusiness Na a (DBA) Address ` <br /> i Owner. t 12J/° Address ` 2 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. v - _ _ =.--Emergency Telephone No. <br /> Contractor Licence No. - <br /> Applicants Name {Print) - Title 0y UE: Date �1 <br /> Please check Applicable Category (1-7) and Fill in the Required information rt , { 4 .,; r QV'I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1,-` June 30, 19 Disposal Sites <br /> I Description(Make/Yr., Color) <br /> Serial No. CAL, License No. .- CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. t <br />' Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> C No, of Vehicles Stored <br /> No. of Chemical Toilets Stored I y <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 /> I Job Address Location _ S - 7 0,v A,0 <br /> O ner }WAddress S <br /> SEPTIC TANK ❑ CESSPOOL Yr LEACHING FIELD- ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> I ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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 I=ar July 1, -June 30, 19 V\ <br /> Operator Name Where Certified <br /> Plant Location ) <br /> i Plant Capacity ¢ No. Units Served <br /> 7. ❑ LAUNDRY For�July 1;-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq: Ft., ❑I More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordanceith San Joaquin County <br /> ordinances, state laws, and rules and reguI tions f e San J quip Local Health District. <br /> .APPLICANT'S SIGNATURE X f_ <br /> i <br /> -FOR DEPARTMENT-USE ONLY <br /> Fee Is Due: ❑-ANNUALLY_ t ❑ PER,UNIT. ❑ PER SITE ❑ EACH _ 40 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE '.EXPLANATION AMOUNT DUE CHECKED . <br /> •c- ---- - -= I - DATE ,DATE - - `REMITTED - AMOUNT - <br /> # FEE -40 <br /> LESS _? <br /> PRORATION - .-- - <br /> PLUS - <br /> PENALTY <br /> OTHER a - - - - - <br /> q ... OTHERIlk <br /> - Recewed-by i0ale ; Receipt No. Permit No. Issuancepatel Mailed Delivered <br /> V APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL .,P.O.Box 2009 STOCKTON,CA 9 1 <br />