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 s her made to c rry b 'ness in 'jrwisdiction al area ofthe S n oa Idjp L al Distri <br /> I Business Name DBA) Address of <br /> aOwner 7Z Address a�P_14 lop- —� <br /> i J Firm Partners, Addresses and Telephone Numbers f1� <br /> a. Business Telephone No. f Emergency Telephone No. <br /> ' Contractor Licence No. ' `! <br /> LApplicants Name (Print) Title !g� �- Date : 2 <br /> Please check Applicable Category(1-7) and Fill in the Required Information �1 <br /> j 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <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 - 1 <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 i <br /> Job Address/Location gz <br /> Owner Address mczzwie <br /> ❑ SEPTIC TANK - C SSPOOL LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> f ❑ PERMANENTt ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> k Type Construction Disposal Site <br /> E 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 /> rE Plant Capacity No. Units Served <br /> f 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this apULication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rul and eguia ' of the San Joaquin Loca Health District, <br /> APPLICANT'S SIGNATURE X f <br /> C <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> hFEE <br /> LESS I <br /> PRORATION .100 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No -Permit No. I suance ate Mailed Delive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box2009 STOfkTON,CA 9 201 <br />