Laserfiche WebLink
Applications WIII Be Processed When Submitted <br /> APPLI ropeny <br /> ,�. (For Non-Transierable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio �lereby r�rlade t c r on b siness in the juri fictional area of the San-Joaquin Local H�fealth Dista <br /> A dress <br /> 3usine5s Name 0;B -- <br /> �P-� Address_ <br /> owner - - - - (/ ----- ---..—--- <br /> Firm Partners, Addresses and Telephone Numbers ---- <br /> Emergency Telephone No.—-----— �, <br /> Business Telephone No. <br /> Ito <br /> Contractor Licence No.— - 2 Title Date <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information LP <br /> lj <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -- <br /> For July 1,--June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color)— 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, 19No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. _ -- — <br /> R.S. or R.C.E. Name — — Test Date/Time -- <br /> Test L cation , <br /> 4. SANITATION PERMIT yl <br /> Job Addres Location �2 — <br /> Address LJ pACKA PLANT <br /> Owner ❑ LEACHING FIELD ❑ SEEPAGE PIT <br /> ❑ SEPTIC TANK ❑ C S POOL ❑ REPAIR ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY C3 NEW <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> _ Disposal Site '-' <br /> Type Construction 4 nt Storage/Cleaning Location(s) <br /> No. of Units --- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 Where Certified — V <br /> Operator Name — — --� <br /> Plant Location _- No. Units Served - <br /> Plant Capacity - <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19— -- e <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. % <br /> ( <br /> I hereby certify that I have prepared i ufapplication e n that the work Local ll l ll be done <br /> Disi ct accordance with San Joaquin County <br /> ordinances, state laws, and re rules g — ' — <br /> qu <br /> APPLICANT'S SIGNATURE X — <br /> FOR DEPARTMENT USE ONLY <br /> ' [] January 1 &Received BY January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH REMIT <br /> $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS !/ <br /> PRORATION <br /> I PLUS / -�- <br /> f+ PENALTY l �� <br /> OTHER <br /> I OTHER <br /> b Le a '4 ' <br /> ` - I suanc Date ►Railed Delivered <br /> 1I Receipt No. Permit No <br /> Received by • Date 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON;CA 85201 <br /> Aow WANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />