Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ��J 2/ (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> 7C. ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness Name (D A) __ _ Address <br /> Owner ?/ •� L`' ll/:s .f l _ <br /> ��_�!7� .��r/� Address <br /> J Firm Partners, Addresses and TelephoNumbers J� <br /> Eo. <br /> Business Telephone No Emergency Telephone No. <br /> Contractor Licence No. <br /> a I7 t/i� iKin` ✓ <br /> _Applicants Name (Print) .� :- 7 <br /> - _ __` - Title Date <br /> -_ - _-- -- <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 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. $0 PERCOLATION TEST — LL <br /> or R.C.E. Name •-, ::r• mor R.C.E. No./ <br /> Test Location A9 9✓ /,- Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> Type Construction Disposal Site <br /> Nc. of Units Equipment Storage/Cleaning Location(s) <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 - <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 /> Home owner or rrensed agen•'ssignature certmesthe following: 'I reftlffyy that In the perforrnaiceof the work for which this permit is issued.I shall not employ any persen <br /> n such manner as to become subject to workman conipen,ar::: ;a,..t1!Caji!o <br /> Contractors hiring or sub-contracting ui ina rtc '- w ,.jiov tng; I certify that in the performance of the work for which this permit is issued.I shall <br /> employ persons subject to workman's compi:nsdh.m iaw,,ui Cial,iiiii i.' <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 regulations of theS n Joaq In Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> 1 f <br /> FOR DEPA RTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> / DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3-9 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />