Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> q� APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> f V ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati n , eby a to car bu in s in the jurisdictional area of the S oa LocAl H alth strict <br /> to Business a (DBA) Addre s - �I r <br /> aOwner f Addre s '� r <br /> Firm Partners, Addresses and Telephone Numers � "� <br /> Emergency Telephone No. ''�' <br /> FL Business Telephone No. <br /> _J Contractor Licence No. 0 <br /> L Applicants Name (Print) '�) S-[9 CZ LF Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) a\ <br /> Serial No. CAL. License No. CAL. License Renewal No. v� <br /> Capacity Gal.,Weights & Measures No. i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> i <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> A.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> I <br /> 4. SANITATION PERMIT <br /> Job Addres /Location _ 33 <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL OLEACHING FIELD B-SEEPAGE PIT ❑ PACKAGE PLANT UJ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ga"REPAIR ❑ OTHER wl <br /> 5. ❑ CHEMICAL 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 <br /> Where Certified <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 hereby certify that I have prepared th�icatlon a h t th work will/1cordance with San Joaquin County <br /> ordinances, state laws, and rules an eg Ions of the oa in Local H <br /> APPLICANT'S SIGNATURE X <br /> 4 <br /> FOR DEPARTMENT NLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ anuary 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING E ANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEES ~ <br />' LESS <br /> PRORATION <br /> PLUS <br />` PENALTY <br /> i OTHER <br /> OTHER <br /> � p <br /> Received by Date Receipt No Permit No. Is"suance Oate Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br /> r <br />