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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> ±� Applicatio .is hereby ade to car on business in the ju .sdictional area of th an aaquin Loc�LlealtDict <br /> Business Name (DBA) sLt/J Address.- S <br /> a Owner Address <br /> Firm Partners, Addresses and Tel hone Numbers <br /> a. Business Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date 7 <br /> Please check Applicable Category (1-7) and Fill in the Required Information r <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 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. t PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ovation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addr s/L c ion N <br /> Owner Address f <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY1-1'NEW ❑ REPAIR 11 OTHER rn�� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 "1 <br /> Type Construction Disposal Site I1 <br /> No. of Units Equipment Storage/Cleaning Location(s) �I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July l,'-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <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 /> 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, an rules and re lations of a an Joa in Local Health District. <br /> i <br /> APPLICANT'S SIGNATURE X I <br /> FOR DEPARTMENT USE ONLY k <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED - <br /> AMOUNT <br /> FEE 4j <br /> t4_5) <br /> LESS <br /> PRORATION -� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> - r <br /> OTHER <br /> 70N <br /> `sceived by - Date Receipt No. Permit No. { suance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1$01'E.HAZELTON AVE.,P.O.Box 3009 STOCKTON,CA 95201 - <br />