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 /> "T ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is ereby mWe to carry on business in the jurisdictional area of the San Joaquin Local Health Distrii <br /> OBusiness Name (DBA) 'EL Address <br /> aOwner _ 1. %ice Address <br /> Firm Partners, Addresses and Telephone Numbers_ <br /> CL <br /> Business Telephone No. ___ __ � '� _ Emergency Telephone No. w <br /> Contractor Licence No. <br /> dc <br /> Applicants Name Name (Print) Title AAc,J� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information j # <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites d <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. 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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT D 1 <br /> Job Address Location /C tris/S c <br /> Owneri �Ci .7 Jf A1_ 1��7A &7— Address <br /> ❑ SEPTIC TANK CESSPOOL 5 <EACHING FIELD ❑ S EPA'GE PIT ' ❑ PACKAGE PLANT- <br /> 13PERMANENT ❑,TEMPORARY ❑ NEW, PAIR ❑ OTHER <br /> 5. ❑ 61-1 MICAL TOILETS For-July 1,.-June 30, 19 �Rti <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) jy <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, —June 30, 19 <br /> Operator Name _ Where Certified I <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and-rules.and regula' ns._orf,.tthhe San-Joa uin Local Health District. <br /> APPLICANT'SSIGNATUREX �� � <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION 'DATF� DATE REWTTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE r �� <br /> LESS ` <br /> PRORATION -- ' <br /> PLUS <br /> PENALTY l <br /> OTHER <br /> OTHER ., y <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ` �r <br />