Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. <br /> APPLICATION <br /> _ (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> App icat' is hereby ad on bus' sin the jurisdictional area oft San Joagruiri �Healthistrict Q <br /> Address ``yy <br /> ,n Business Name (DBA) <br /> Address += <br /> aOwner <br /> j Firm Partners, Addresses and T 1 phlone Numbers I' <br /> a. Business Telephone No. <br /> OQ Emergency Telephone No. <br /> Contractor Licence No. Title Date )® <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information ±� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) E I <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No, <br /> Serial No. CAL. License No. <br /> Gal., Weights & Measures No. <br /> Capacity <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 R.S. or R.C.E.No. <br /> R.S.or R.C.E. Name Test Date/Time <br /> Test Location 629 <br /> 4. ❑ SANITATION PERMIT n <br /> Job Address L cation 9 C-..> C) s ) <br /> �J 1 ,115 Address <br /> Owner LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> �+SEPTIC TANK Cl CESSPOOL ❑ REPAIR El OTHER <br /> PERMANENT ❑ TEMPORARY NEW Q <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site S <br /> No. of Units Equipment Storage/Cleaning Locations} <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No, Units Served <br /> Plant Capacity <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 applic .i and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and atlo o he Joaquin Local Health District. <br /> 02 <br /> APPLICANT'S SIGNATURE - Oy <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. - ❑ January 1 &ReceJuly 1 &Received 8y July 31 <br /> Received By January 31 ❑ <br /> REMIT r <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS t <br /> PRORATION - <br /> PLUS C <br /> PENALTY \ <br /> OTHER 1 <br /> OTHER <br /> 3� 3 /6 �� to l9 <br /> Receipt No Permit No. Iss c D e Mailed Dehvered <br /> Received by Date <br /> 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />