Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ';hereby made tdci,on business in the jurisdictional area of the S Joaquin Local Health District <br /> r Business Name {DBA)- ^�''� 4f/Q�/tr f-�' Address .- <br /> :?q Owner_ Address _ <br /> Firm Partners, Addresses and Telephone Numbers <br /> .Q Business Telephone No. r Emergency Telephone No. <br /> Contractor Licence No. l <br /> Applicants Name (Print) Title Date <br /> Please check Applicable allegory (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) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity 4 Gal.,Weights& Measures No. ? <br /> i9 <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 l <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/ me <br /> 4. ❑ SANtTATION PERMIT / <br /> Job Address/Location J D r� [ `" L <br /> iI Owner Address <br /> CRSEPTIC_TANK� ❑'CESSPOOL 014 EACHING FIELD 0SEEPAGE PIT` ❑ PACKAGE PLANT <br /> 0-PERMANENT ❑ TEMPORARY 11NEW ❑ REPAIR ,"OTHER <br /> • 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site } <br /> No. of Units Equipment Storage/Cleaning Location(s) z' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 'F 1 <br /> Operator Name I Where Certified <br /> Plant Location <br /> Plant Capacity No.Units Served DQ <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> s c c <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home oWflerorliannse0agent's '.he fo"510,.",in3y 1 csr€ifythatinthopericrmance,3ft;le'por! for-which this permit is issued,tshall notempinyanygerson <br /> In such manner 25 to become 5UbieC1:0,vv;!-;-in;8r': <br /> !: Contractor'- h1dilg or sub-con'trnzl.nns:x�iss-w.c:^�t,ic: ^iac�:fnti�wislg: "I eortify ih21 in the perfarmance of the woek fm athich the Permit is issue'1,l st,ail <br /> employ persons suhject to weri.nlan's ca np l�satier,laws of Ca:itot iib l <br /> 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 an .regult .ions of;he San Joaquin Local Health Distri t <br /> APPLICANT'S SIGNATUR ,X <br /> fl <br /> a FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑PER SITE f'❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &i.Received By July 31 <br /> ' REMIT <br /> BILLING REMITTANCE $ <br /> RASE EXPLANATION AMOUNT UUE CHECKED ¢' <br /> �. DATE DATE REMITTED AMOUNT j <br /> r <br /> FEE <br /> a <br /> LESS <br /> PRORATION' <br /> PLUS J} <br /> PENALTY <br /> I" OTHER '.'4,1 C .,t`" ; <br /> bTHER <br /> 106 <br /> Received by Date ``\\ Receipt No, errni[ o, -- Issuance Date Mailed Delivered - • , <br /> APPLECANT=RETURN'ALL COPIES TO: EItt"RONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i <br /> `a <br />