Laserfiche WebLink
r, tApplEcations WEII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application..-- <br /> .3t:,. - APPLICATION - <br /> (For Pion-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT �. <br /> LIQUID WASTE 1 <br />[ Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness N e BA) Address <br /> i Owner Address <br /> i'> a <br /> k Firm Partners, Addre�, .Iqpne Numbers <br /> G& Busp Emergency Telephone No. <br /> Business Telephone No. <br /> a <br /> Contractor Licence No. 1 <br /> Applicants Name (Print) Title / ' Da1e <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> k- 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> 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 <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. ❑ SANITATION PERMIT <br /> Job Address/Lo ation <br /> Owner <br /> Address <br /> f SEPTIC VANK ❑ CESSPOOL_4%LEACHING FIELD J,SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> 1 No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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 this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and regulations of the San Jo quin Local Health District" s <br /> APPLICANT'S SIGNATURE X <br /> ) <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> r `{ <br /> PENALTY -%.V Q ✓Z <br /> i <br /> OTHER <br /> OTHER <br /> 4- . <br /> o -�'i'��-.• . <br /> Received 6y - - Date Receipt NO Permit o. 15Suanc:�& <br /> ailed Delivered <br /> ~APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PF Permit <br /> 1601 E.HAZELTOBOK 2009STOCKTON,CA 95201 <br /> i � .E <br />