Laserfiche WebLink
bmitted Properly Completed. Be Sure io bign 1n <br /> Applications Will Be Processed When Suc <br /> .+NN .a•�••• <br /> APPLICATION <br /> = . (For Non-Transferable, Revocable, and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is rade t arty business in the'urisdictional area of the San Joaq�iLocal Health Dist ict <br /> f r Address <br /> OBusiness Na a DBA) ` Address <br /> z Owner <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. ) <br /> Contractor Licence No. r Date <br /> �- Title j <br /> Applicants Name (Print) 1 <br /> Please check Applicable Category (1-7) and Fill in the Required Information W 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 Disposal Sites <br /> l Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> i Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> r 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 R.S.or R.C.E. No. + <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT 7— <br /> ( Job Addres ocafi n , <br /> [ Owner �" Address <br /> . EPTIC TANK ❑ CESSPOOL '�bEACHING FIELD SEEPAGE PIT 0 PACKAGE PLANT <br /> y BOTHER <br /> �ERMANENT ❑ TEMPORARY W ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> t Disposal Site - <br /> Type Construction <br /> k Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> k 6. C1 PACKAGE TREATMENT PLANT For July 1, - June 30. 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1' -June 30, 19 <br /> SIZE: C3Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> E. <br /> re ed a Ic ion and that work will be done in accordance with San Joaquin County <br /> I hereby certify that I have p <br /> ordinances, state laws, an u a e ti s the San 04 <br /> uln Lo I Health District. <br /> k APPLICANT'S SIGNATURE X <br /> 11 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE 13 EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRd By 31 <br /> IT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE - EXPLANATION DATE DATE REMITTED AMOUNT <br /> D <br /> FEE p <br /> LESS <br /> PRORATION <br /> PLUS <br /> i PENALTY <br /> I <br /> OTHER <br /> OTHER l L <br /> Received by Date f Receipt No. <br /> Permit No Issuance D Mailed Delivered <br /> 1601 E.HAZELTON .D.90=2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �; <br />