Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION <br /> 1 (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i reby made ca on bu ess in the' isdi tional area of the S oaquin Local Health District <br /> i f <br /> yBusiness Name BA) C� Address <br /> z Owner Address . <br /> a <br /> Firm Partners, Addresses and Telephone Numbe <br /> IL a Business Telephone No. l� r p Emergency Telephone No, <br /> Contractor Licence No. r ) <br /> L Applicants Name (Print) Title Date J <br /> Please check Applicable Category (1-7)anAd Fill in the Require 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 <br /> Job Address/Lootion <br /> Owner Address Q& ez>e <br /> ❑ SEPTIC TANK ❑ CESSPOOL ° LEACHING FIELD ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY # ❑ NEW REPAIR ❑ OTHER cZ] <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> j No. of Units Equipment Storage/Cleaning Location(s) <br /> fi 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> 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 <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 rules a regulation of t Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - - <br /> FOR DEPARTMENT USE ONLY <br /> M <br /> 1 - Fee Is Due: ❑ ANNUALLY - ❑ PERUNIT ❑ PER SITE ElEACH ❑ January 1 &Received By Janua ❑ J ly 1 &Received By July 31 <br /> t REMIT <br /> BASE .jEXPLANATION BILLING REMITTANCE - AMOUNT DUE H CKED <br /> DATE DATE REMITTED LINT <br /> FEE r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> (DC) <br /> Received by Date 'Receipt No Permit No, Is ante ate Mailed Delivere <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br /> P <br />