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 /> r Applicatio is hereby de to Car n busing 5 in the jurisdictional area of the S Joa in Loyal Hea District <br /> rBusiness ame (DBA) Addres <br /> Address <br /> z Ownerw-,-�--52 <br /> U Firm Partners. Addresses and T lephone Numbers <br /> Business Telephone Na. Emergency Telephone Na. <br /> Contractor Licence No.._�[�)5 1 <br /> Applicants Name(Print)—tC.�t6 £t 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 /> j Serial No. CAL. License No. CAL. License Renewal_Na. <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 /> k 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 Loation Test Date/Time - <br /> 4. L SANITATION PER 1T <br /> Job Address/ cation - <br /> Owner Address <br /> WTIC TANK 13 CESSPOOL -LEACHING FIELD QSEEPAGE PIT 13 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW WREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30. 19 _- d <br /> Type Construction_. Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified -.- <br /> t Operator Name <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 applicati and th t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul re lotions a Joaquln Local Health District. <br /> i APPLICANT'S SIGNATURE X <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ ,January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuIy 31 <br /> 81LLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE S c y5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> V <br /> Received by Dare Receipt No. Permit No Issua ce Dae Mailed Delivered <br /> iiam a uasF1 TnN&UP P O-801'2W9 STOCKTON.CA 94201--r <br />