Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> mor Non-Transferable, Revocable,and Suspenda*,. y / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT y <br /> LIQUID WASTE <br /> Application is ere made to c ry n sines i the jurisdictional area of the San Joaquin Local Health District / <br /> ,f-Business Name DBA) Address J f <br /> ? Owner_ t/ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q Business Telephone No. / 6 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> 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 /> `+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. ❑ 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. ,SANITATION PERMIT T <br /> Job Address/Location ��5�1 IL�/ Ae,6 <br /> Owner L2C�,S liu:a!S Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD MjSEEPAGE PIT ❑ PACKAGE PLANT ti <br /> Yy❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �� pe - : — <br /> Type Construction Disposal Site Q <br /> No. 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 /> Homeowner or licensed agent's signatusAeartifienthr.1-!1.owinn:"Irertifythmht.'"np.rfnrm$ncP,offttP.Hinrkfor tohichthis permit isissued,fsnallnot iry,,,-.v peisor, <br /> in such rnanner as to beceirie subject t0 hrk^a1(' ✓:{;' ?%.'^r;• alt,' ;r . <br /> Contractor's hiring or sub-contracting !;c-,tratvra certifier trr_ 11"o.viog: 'i rur lily tha:tit the pei forinance of the work for which th' ,_ i P ,:<' ',I <br /> employ persons subject to workman's compensation laws of California," <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, and rul nd reg tions o the San Joaquin�Local Health District. <br /> "APPLICANT'S SIGNATUREX _ 4/ <br /> FOR DEPARTMENT 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 /> BREMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE i z4A ' <br /> J o� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> 1 <br /> OTHER 1 O <br /> Received by Date Receipt No. Permit No. a <br /> ssuance te Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT E.,P.O.Box 2009 STOCKTON,CA 95201 <br />