Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> APPLICATION i <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby pade to carry A bu in ss in the jurisdictional area of the S n oa n Local Health trict /J <br /> FBusiness a (DBA)i Address r� <br /> QOwner l Ad ress <br /> J Firm Partners, Addresses and Telephone Numbers K 7� `a��� <br /> OIL <br /> ILBusiness Telephone No. �� � �� Emergency Telephone No. <br /> Contractor Licence No. .905 7.21 <br /> r—A Title (cc7�C. Date /.� <br /> L Applicants Name (Print) <br /> Please check Applicable Category(1-7) and FIII 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., Calor) <br /> E CAL. License'No. CAL. License Renewal No. <br /> Serial 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 V <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. V` <br /> i Testt Lo ation Test Date/Time <br /> 4. L`S SANITATION PERMIT ` <br />} coca – o mac.• - <br /> Job Addre s/Location *M <br /> Owner Address <br /> ❑ SEPQ,TANK ❑ CESSPOOL 19r'LEACHING FIELD 09-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 9? REPAIR ❑ OTHER w` <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. 11 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 /> I hereby certify that I have prepared this app' ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, r s and regula San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> ( FOR DEPARTMENT USE ONLY <br /> Fee IS flue: ❑ ANNUALLY © PER UNIT ❑ PER SITE © EACH ❑ January 1 &ReceivedByJanuary 31 ❑ July 1 &Received By July 31 <br /> REM <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE C D <br /> DATE DATE REMITTED A - <br /> k FEE S \ <br /> F LESS . <br /> F PRORATION <br /> L PLUS €€ <br /> PENALTY Y <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 ErHA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> y <br />