Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> -„ APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San�Joaquin Local Health District <br /> .F. Business Name (DBA) �- cD 'd 1 C & Back o "Address ` <br /> d owner .. T R , McDonald Address Same <br /> Firm Partners, Addresses and Telephone Numbers1 <br /> CL <br /> Business Telephone No:9.31 '- 49 7 Emergency Telephone No;- 957-027 <br /> Contractor Licence No. '. <br /> Applicants Name (Print) D• a d Title Owner Date .-. <br /> 1 ' <br /> Please check Applicable Category (1-7);and fill in the Required Information <br /> For July 1, June 30;19 Disposal Sites <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)1% <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 t <br /> No. of Vehicles Stored _ 1• '! <br /> No. of Chemical Toilets Stored- - f <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. 1:1SANITATION PERMIT 1 <br /> Job Address/L atioA - 4 <br /> weer Address <br /> SEPTIC TANK ❑ CESSPOOLLEACHING FIELD rSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY E] NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Site <br /> Type Construction � �' Disposal , <br /> Equipment Stora a/Cleanin Locations <br /> No. of Units9 9 O <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �3 `� - x ✓ ` <br /> Operator Name <br /> r 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 /> r ; <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> k ordinances, state laws nd rules and re tions of the Sa oaquin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> Z <br /> FOR DEPARTMENT USE ONLY OV <br /> i <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Jr <br /> t <br /> LESS <br /> PRORATION <br /> PLUS # <br /> PENALTY <br /> OTHER " <br /> OTHER <br />' Receive Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPL ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />