Laserfiche WebLink
APPLICATION <br /> rit Non-Transferable, Revocable, and Suspendat <br /> -' ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati h eby ma to car on business in the jurisdictional area of the San Joaquin Local alth istr t <br /> HBusiness N me (DBA) Address <br /> aOwner Address D <br /> 70 Firm Partners, Addresses and Tel phone Numbers <br /> IL <br /> Business Telephone No. ?'CD 3 ' + � Emergency Telephone No. <br /> Contractor Licence No. Ifr <br /> Applicants Name (Print) Title ` Date "'fd �� C <br /> Please check Applicable Category (1-7)and Fill in the Required Information i <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. Lir:ase Rertewal 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 <br /> Job Addres Location Z- <br /> yO�wner14 Address <br /> 1 SEPTIC TANK ❑ CESS OL LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT <br /> 19 PERMANENT ❑ TEMPORARY V NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served C <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 /> - 1 <br /> I <br /> I hereby certify that I haveprared this application and that the work will be done in accordance with San Joaquin Countyordinances, state laws, a d regulations of San aquin Local Health District. 4 <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE .-DATE REMITTED <br /> AMOUNT <br /> Y5p0 o t7 <br /> FEE (� <br /> LESS <br /> PRORATION 4' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> wav <br /> OTHER t r <br /> k <br /> r <br /> Received by Date Receipt No. Permit No. Issuance Date - Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />