Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> p (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i re� mad to ca ry o usin sin a juri tionai area of the S Joa in Local <br /> Health District <br /> N Business Name (D ) <br /> r A dress <br /> i Owner <br /> Address <br /> a <br /> J Firm Partners, Addresses an T le h ne Numbe <br /> IL Business Telephone No. �� a Emergency Telephone No. <br /> d <br /> � Contractor Licence No. , <br /> L Applicants Name (Print) <br /> Title Date <br /> Please check Applicable Category (1-7) and Fill in the Requl d 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 /> 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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/ cation -51 <br /> Owner Address <br /> E] SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD P SPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT 13TEMPORARY C1NEW LOOIREPAIR ❑ OTHER '~ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site r-k <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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 <br /> I hereby certify that I have prepared this application and that the work will be done in accord's ce wilh�San Joaquin;County <br /> ordinances, state laws, and ruleprid regulation of San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br />' FOR DEPARTMENT USE ONLY <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 <br /> LESS <br /> PRORATION {{ <br /> PLUS ♦` <br /> PENALTY y ' <br /> OTHER {1 <br /> OTHER <br /> /6593 al'30zs <br /> Received by Date Receipt No. Permit No I Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> IRe.CA;2A,1cf -',t 4„4k�A* 2.;;'--Alar, �� <br />