Laserfiche WebLink
APPLICATION <br /> t! ,J (For Non-Transferable,Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby e t carry o busi s in the' 'sdic on�aa reaAddrAdd( osthe r� loo U�n,L al alth 4istrict —� <br /> s �` W <br /> Business ar (DBA) r Address — — <br /> d7_V -/_ <br /> — — <br /> Owner -- -- <br /> Firm Partners. Addresses a��le7honeNumbers Emergency Telephone No. - — <br /> Business Telephone No. <br /> Contractor Licence No. - <br /> ---� Tilt Date_----— �. <br /> Applicants Name (Print}_ <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 -- <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) . . <br /> June 30, 19 Disposal Sites t — — —— <br /> For July 1• ----- <br /> CAL. License Renewal,No. <br /> Description(Make/Yr., Color) CAL. License No. — <br /> Serial No. -- <br /> 1 Gal..Weights &Measures Na. <br /> Capacity — <br /> — <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 R.S. or R.C.E. No. <br /> R.S. or R.C,E, Name `= Test Date/Time -- — <br /> Test ocation <br /> 4.. SANITATION-PERMIT = 0 p <br /> Job Addss;Lo ation <br /> Address ' <br /> Owner . ❑ SEEPAGE PIT• ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING F1EL0 13 OTHER <br /> ❑ TEMPORARY ❑'NEW ❑ REPAIR <br /> C3 PERMANENT y <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 1Disposal Site — <br /> Type ConstructionEquipK_ <br /> ment Storage/Cleaning Location(s) <br /> No. of Units 1,-June 30, i9 I <br /> g. ❑ PACKAGE TREATMENT PLANT For July Where_Certified <br /> Operator Name <br /> Plant Location _ No. Units Served <br /> i Plant Capacity — f <br /> i 7. 11LAUNDRY For July 1, -June 30,❑19Mor�e Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq, Ft.. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/.Mo. <br /> r <br /> r' application and that the work will be done In`accordance with San Joaquin County <br /> V I hereby certify that I have prepared this app <br /> t <br /> r ordinances, state la , a d rules and.r lotions of the San Joaquin Local Health District--- f — <br /> l1d^y <br /> I App�NT'S SIGNATURE X — - �� � '•— I ti. _ <br /> k f ' FOR DEPARTMENT USE ONLY y <br /> 1 <br /> I � � 8 Rec By January 31 ❑ July t &Received By July 31 <br /> ❑ January _ REMIT <br /> T <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT i ❑ PER SVTE EACH CHECKED <br /> REMITTANCE $ - AMOUNT DUE AMO--- T <br /> I EXPLANATION i 6DAILL TEO DA REMITTED <br /> BASE b S <br /> f � <br /> FEE "tS-d <br /> LESS ---- <br /> PRORATION } <br /> ' PLUS <br /> PENALTY <br /> OTHER 1 I <br /> OTHER <br /> �issua�i7ate�� Mallad Delivered �_` <br /> �Rec <br /> Receipt No. Permit.:c. "-. . . TOCKTON,CA 95201ate 1601 E.FiAZELTON AYE..P.O.eox 20119 .S RETURN ALL COPIES TO: ENVIRONMENTAL HEALTM'PERMITlSERVICE9 y , <br />