Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r a>. (For Non-Transferable, Revocable,and Suspendable) SEPTAGE I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereby made t carry on business in t jurisdictional area of the Sann�oaguuiin Local Health District <br /> OF Business Name (D8A) - ' Address— � <br /> ,�- 2f? <br /> z Owner Address <br /> d .; <br /> J Firm Partners, Addresses and Telephone Numbers tJ <br />$ Business Telephone No. 6 S Emergency Telephone No. <br />� Contractor Licence No. �� � <br /> L Applicants Name (Print) i Title Date <br /> Please check Applicable Category (1-7)and Fill in theRequire 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 Na. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD w <br /> For July 1,_ _June 30, 19 <br /> No. of Vehicles Stored- <br /> No. of Chemical Toilets Stored .i <br /> 3. ❑ PERCOLATION TESTV� <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Test Location * ! Test Date/Time r <br /> 4. ❑ SANITATION PERMIT I <br /> Job Address/Location ry <br /> I "` Address <br /> Owner <br /> 13SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 0 PACKAGE PLANT <br /> ❑ PERMANENT ElTEMPORARY 0 NEW n FSEP y 0 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, - Junef30, 19 <br /> Operator Name ! ! Where Certified <br /> Plant Location _-f I °� . s rK <br /> Plant Capacity �) No. Units Served <br /> 7. ❑ LAUNDRY For Juiy,1,-June 3019) ¢ <br /> .1 49 "0" i r <br /> SIZE: ❑ Less Ttian 1,000 Sq.'Ft.., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING Chemicals Used/Ainount/M6. ' <br /> I hereby certify that I have 1prepared this application and that the work will b6-done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an regulations of th 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 C� AMOUNT <br /> FEE t. <br /> LESS <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> k <br /> OTHER <br /> I <br /> Received by <br /> Date Receipt No. - Permit No. ISs anc vered <br /> Date M filed Deki <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.NAZELTON AVE.,P.D.Box 2009 STOCKTON,C0.95201. <br />