Laserfiche WebLink
33 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 '`t <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Address <br /> aOwner Address _- <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone-No,._ <br /> Contractor Licence No. <br /> L Applicants Name (Print) t 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., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity 4 Gal:, Weights & Measures No.� <br /> I. <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 9 -. <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 °Y❑<CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ; ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1f -June 30, 19 h <br /> Type Construction' k �+� Disposal Site i <br /> -. Equipment Stora Storage/Cleaning Location(s) <br /> No. of..Unitsg 9 ( ) <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 t <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" t' <br /> Homeowner orticenwirl Aaent's elgn Burs certifies certifr that in then-f6r-mance of the work for which this permit is issued,I stall not employ any person <br /> insuehmanner as to beeGlre sobject 1q:a,orkma.n's compel sP';ur lnwt of�i3,.f�f.`.iH:' ! , <br /> Contractor's hiring or,sub-rflht-trtir:� g.::t,.,ra cer,',.iss t%_- 1o4owingc "i certify that Lit the perfc mance of the work for whichthcs iermit is issued,I shath <br /> employ pBrso�ls SuiijecL t0'NGF}iilai,'S�Gittyr;iSutlGii IGS`15 of caliiornia.' I <br /> - f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> �•. V..` F Prq <br /> APPLICANT'S SIGNATURE X <br /> FOWDEPARTMENT USE ONLY <br /> Fee Is Due: 13 ANNUALLY ElPER UNIT ❑ PER SITE 13EACH ❑ January 1 &Received ByJJanuary 31 ❑ Ju y.1 &Received By July 31 <br /> REMIT <br /> •BASE - EXPLANATION BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> 5 f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY '°` 'p""•'�- .,y. .ti <br /> OTHER <br /> OTHER <br /> Received by Date Receipt NOL Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 21309 STOCKTON,CA 95201 <br />