Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Reirocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h y made to car on busine s in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Nam DBA) Address <br /> z Owner � Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title ZZ001— Date <br /> 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 /> 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 cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Jab Address/Location <br /> Owner Address .c57tQ��.a G <br /> y/ _ <br /> R7 SEPTIC TANK ❑ CESSPOOL CO-LEACHING FIELD ASEEPAGE PIT ❑ PACKAGE PLANT 0 <br /> f�PERMANENT El TEMPORARY A NEW ❑ REPAIR ❑ OTHER p(} <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 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 /> Hornb owmrorticensed agent's signature certifiasths following:"t certify that in the p ertorm ance of thework for which this permit is issued I shall not employ anyperson <br /> in such mariner as to Wcome subject to workman's cumpeasatiosl Faws of Californi I <br /> contractor's hiring or sub-contracting sign :signature certifie tha lotlowing: "I certify that in the performance o,the wofk for which thlS permit is issued,i shall <br /> employ persons subject to workman's compensation laws al California" <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, and rules and r ations of a San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 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 AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE S \ <br /> LESS N- <br /> PRORATION ` t <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O � <br /> Received by Date Receipt No Permit No. iqsuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />