Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> �. APPLICATION <br /> (For Non-Transferable, Redocable, and Suspendable) SEPTAGE <br /> 9 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is e y ade to ca s in 11,re jurisdictional area of the San.J quin Lo eaIth District <br /> Address - <br /> y Business Name <br /> z Owner= Address <br /> J Firm Partners, Addresses and Tep one Numbers <br /> aBusiness Telephone No. - Emergency Telephone No.� <br /> Contractor Licence No. r _ - <br /> l/ i, .Title Date <br /> �Applicants Name (Print) 'f" - - W <br /> Please check Applicable Category (1-7)-and I 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 Gal.,Weights & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 I <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 0-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. ❑ SANITAT"CESS <br /> OPERMIT d I <br /> Job Address/Lo <br /> Owner Address <br /> ❑ EPTIC TANL ACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> Y EW REPAIROTHER"-'""�. <br /> PERMANEN <br /> 5. ❑ CHEMICAL TOILETS For July 1, - une 30, 191 w <br /> Type Construction S' Disposal Site <br /> No. of Units 1' Equipment Storage/Cleaning Location($) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I" _- Where Certified ' <br /> v a t._.� <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. 1 <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 acdordance with San Joaquin County a <br /> ordinances, state laws,:and rules d gula ' sof the San Joaquin Loc fl h District. . <br /> APPLICANT'S SIGNATURE X _ <br /> G li <br /> l' i <br /> I 'F ; FOR DEPARTMENT USE ONLY <br /> { Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 8 Received By July 31 <br /> REMIT <br /> ' a EXPLANATION BILLING REMITTANCE - c $ AMOUNT DUE CHECKED <br /> BASE _ <br /> DATE - DATE -,",REMITTED AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION <br /> 4' <br /> i PLUS ' _ .-_, - �J I (`1'�eiN �() -h 'fell- L'i'r I -r <br /> PENALTY- t <br /> �L (jeq 4!r Ch <br /> OTHERS <br /> 1y <br /> e OTHER <br /> i _ <br /> eceived by Dat t -Receipt No. A Permit No. ISSuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL,COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> :I <br />