Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> F 2° (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatpi n/is hereb made to carry on business in the jurisdictional area of the an Jo uin Local Health Distri t <br /> yBusiness ame B };/� A Address <br /> z Owner Address <br /> Q <br /> Firm Partners, Addresses and Tele hone Numbers <br /> IL Business Telephone No. Emergency Telephone No. r 7z,7 <br /> a <br /> Contractor Licence No. <br /> LApplicants Name {Print) OL" Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required lRformalion CI <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) $ <br /> For July 1, June 30, 19 Disposal Sites V <br /> Description{Make/Yr., Coior) <br /> ti Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. CJ 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 /> t Test Location Test Date/Time r <br /> ".4. XSANITATION PERM <br /> �I�. <br /> .JobAddr /Location ^I' l .7C)� <br /> "Ownersress <br /> ASEPTIC TANK CESSPOOL Y I ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 7 PERMANENT ❑ TEMPORARY11NEW 0 REPAIR OTHER i71r.3.S S - <br /> 5. 11CHEMICAL 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 <br /> i 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 /> r 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, a les and regulations of the n uin Loc Health District. <br /> APPLICANT'S SIGNATURE Ab 91 <br /> F <br /> z 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 /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> fFEE / <br /> r LESS <br /> PRORATION Me <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> e- <br /> Received by - _ Date - Receipt No.- Permit No. Issuance Date Mailed Delive <br /> 'APPLICANT—RETURN ALL COPIES to: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' <br /> ..- .�� . <br />