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 /> Application is he m e to on,ujess in the jurisdictional area of the San Joa uin Local Health Distr <br /> „r Business Name (DBA) �G Address <br /> I.- <br /> Owner E, Address—­ <br /> :0 <br /> ddress <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. J 6` Emergency Telephone No._ C <br /> Contractor Licence Na. f <br /> L Applicants Name (Print) en Title ���" Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information r <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 <br /> Job Address/Locationn <br /> Owner 44 f Address { <br /> ❑ SEPTIC TANK 11CESSPOOL .9-LEACHING FIELD 41ilfSEEPAGE PIT ❑ PACKAGE PLANT <br /> PeZERMANENT ❑ TEMPORARY JR-NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction . Disposal Site C� <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 /> I hereby certify that I have pared t ' 'app' a ion and that the work will b done in accordance with San Joaquin County <br /> ordinances, state laws, an rule and gull on of the San Joaqu' Local th District. <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> SASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED <br /> FEE , <br /> AMOUNT <br /> � 5 00o <br /> LESS <br /> PRORATION <br /> PLUS ..� <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No ssuance Date Maile D livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />