Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transfeiable:Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE s <br /> Application is h y made to ca on busines the jurisdict'onal area of the Sana quin Local Health Distric / <br /> rn Business Name (DBA) Address 7� 7" T✓`�G�:_� <br /> aOwner dress <br /> J Firm Partners, Addresses and Telephone Numb. <br /> Q. Business Telephone No. �� t�1 Emergency Telephone No. r off\ <br /> Contractor Licence No. <br /> L Applicants Name (Print) - Title Date ��7 <br /> Please check Applicable CZR� <br /> -7) and Fill in th Required lnf motion „r w <br /> 1. ❑ PUMPER VEHICLEREGISTRATION (FOR EACH HICLE) L <br /> For July 1, - . June 30, 19 7Disposal Sites - –_ - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No; t ' <br /> Equipment Parking Address IT- <br /> 2. <br /> T 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. ar E. Name R.S. or R.C.E. No. <br /> Test 4cation T Test Date/Time _ <br /> 4. SANITATION PERIMIT �. . <br /> Job A dress/ cation <br /> Ow r Oil Address <br /> j SEPTIC NK ❑ CESSPOOL LEACHING-FIELD ❑ PACKAGE PLANT <br /> ❑ PERMANENT 1:1 TEMPORARY ❑ NEW EPAIR ❑ OTHER .C:! 5.e. .� <br /> 5. El CHEMICAL TOILETS For July 1,-June 30, 19 — � 41 <br /> ly Ap d <br /> Type Construction Disposal Site c _ <br /> No. of Units Equipment Storage/Cleaning Locations) -' <br /> ti. ❑ PACKAGE TREATMENT PLANT For July 1,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 /> ❑ DHRY CLEANING, Chemicals Used/Amount/Mo. <br /> orne ownerorlicensedager t'ssignaturecar ifiesthef0II0vyin"-;"I certify that in the performance of the work for which this per isissued,I shall not employanyperson <br /> in such manner as to become subject to:torkriit:n's,;;annensatialatavas of California."' <br /> Contractor's hiring or I�trb-santractin� sigrla�;ure cort"io'; hp xallawing: "!certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons sub;ect to workman's cu'mpensatiuri lavas of Cali:ofilia.' <br /> I hereby certify that I have pr red this application and tat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and and regulations of the JDa uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee I$ Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CH CKED <br /> DATE DATE REMITTED A UNT <br /> EEE <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER /J �r/[►� <br /> OTHER - water° <br /> S7 2� a <br /> Received by Date -Receipt No. "Permit No. - - -ilssuancin Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/tERYICES ''" `1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 99201 <br />