Laserfiche WebLink
i r y Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transf4able Rzvocable,Mand Suspendable) SEPTAGE /f <br /> { ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic�isede to Onbu ' ess in the jurisdictional area of the San Joaquin LoJ Health District <br /> rn Business Name BAAddress "�i OwnerC Address <br /> j Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No. Cv Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) d Title; .5 g•• Date <br /> I Please check Applicable Category.(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <br /> For July 1, ` - June 30, 19 -Disposal Sites <br /> f 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 n ti <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.ASANITATION PERMIT <br /> Job Addr s/Location : <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD WSEEPAGE PIT ❑ PACKA3f PLANT <br /> -PERMANENT ❑ TEMPORARY ❑ NEW A;REPAIR Q OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, l9�-� <br /> Operator Name Where Certified <br /> Plant Location <br /> �. ;. <br /> Plant Capacity -r-�• No. Units Served �..,.....l :- �`��'"�'" <br /> 7. ❑ LAUNDRY . For July,1, -'June 30, 19 <br /> SIZE: -❑ Less Than 1,000 Sq!. Ft., ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING, Ctiemicals Used/Amount/Mo. <br /> t. Home rrf <br /> owner the <br /> Eng: lC6rtt#y tnslinperlwmartCeoftheworkforwhichthispermitisisslsed,IshaNrGtemp'ayanyperson <br /> In such manner as to became subject to worNsnan's c9mpensation taws of COMtop ' t <br /> Contractor's hirfnq or sub-conuacting signatu!a certifies the fottowrng: -'f etttify that in the perturmance of;he work for which this permit is issued,-1 shall <br /> employ persons subject to workmareS sompensatlon laws of California." i t <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, a les and gul ons of the San Joaquin Local Health Dist ict. <br /> 1 APPLICANT'S SIGNATURE X <br /> FOR.OEPARTMENT USE ONLY i 4 <br /> _ Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -❑ January 1 &Received By January 31 ❑ July 1 8,Received By July 31 <br /> r <br /> REMIT AMOUNT DUE CHECKED <br /> t BILLING REMITTANCE J s -. <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEELESS <br /> '- <br /> 1 <br /> PRORATION <br /> PLUS <br /> • PENALTY <br /> OTHER — �Ui�f /" r !✓��i �r r 7� "�' f/�iv T' .x.'.L� CC-Fs sr ' <br /> OTHER .. .f,•'��,:.� -..-�."rI�r �' ' . - _ .F f . <br /> _„.Received,by Date Receipt No. Permit No. 1s anc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />