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 is reby Te t4 car on business in the jurisdictional area of the San Joaquin Local Health District [� <br /> WF Business Name (DBA) et C►_ Address 'QSX5 E XW S'�""• <br /> i Owner jfxAift Address � 7C� <br /> a <br /> J Firm Partners, Addresses andele hone Numbers <br /> a Business Telephone No. � 7 Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> L Applicants Name (Print) _ Title Date <br /> Please check Applicable Category (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 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. f hemical Toilets Stored <br /> 3.kRCOLATIONTEST <br /> R.S. or R.C.E. Name b/lJ �I�//UZ� R.S or R.C.E. No. �✓ <br /> Test Location A5.1• Test Date/Time S _ <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 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 /> I hereby certify that I have prepa his plicatiodaJ';Kir\' <br /> ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r le r atione-of,tLocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT SE OY <br /> Fee Is Due: <br /> El ❑ PER UNIT ❑ PER SITE ❑ EACH J 4.. <br /> 1 8,Received By January 31 ❑ July 1 8,Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING I E $ AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M/ UP 3b& <br /> r <br /> Race e y Dafe I Receipt No. ermit No. Issuance Date Mailed Delivered <br /> A PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />