Laserfiche WebLink
— �r <br /> -' plications Will Be Processed When Submitted Properly Completed. Be Sure To Sign a pp is <br /> Ap - APPLICATION c <br /> f (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> .� • ENVIRONMENTAL HEALTH PERMIT <br /> - LIQUID WASTE al <br /> n LOC <br /> �f <br /> Application is hereb ad to carry on tZUsin�ss i the ji r�Cie ibnai area of the San 4�45U1 H7 dX Ol h District <br /> 1-IcDona�lept1C an V Address <br /> y Business Name (DBA) same <br /> aOwner • R- men— � Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. — Emergency Telephone No. <br /> 4 <br /> Contractor Licence No. Title Qtdl i P_T Date <br /> L Applicants Name (Print) <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.,Color) CAL. License Renewal No. <br /> Serial No, CAL. License No. t <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 R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location , 31 Fini- <br /> 4.4. ❑ SANITATION PERMITS�� <br /> 7-- <br /> Job Address/Location, Zj a - <br /> Owner Address <br /> LX,SEPTIC TANK ❑ CESSPOOL LEACHI G FIELD 'SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ <br /> 11 PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER ` <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> in Location(s) <br />� <br /> Equipment Stora a/Glean g <br /> No. of Units Equ p g �.. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> 3 <br /> p <br /> I hereby certify that I have prep <br /> ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule Ind re ulations he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> i 31 <br /> ❑ SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT Fee Is Due: ❑ ANNUALLY El PER UNIT PER <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ( BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE m M, <br /> LESS <br /> PRORATION <br /> PLUS r v <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Mailed Delivered <br /> Received by Date <br /> Receipt No. Permit No. Issuance Date <br /> 1601 E.HA .,AVE.,P.O. 20 <br /> ON,STOCKTON,CA 9524 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITISEAYiCES � <br />