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 hereby made to carry onb mess in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA) -.'Address e-?.V �G�C <br /> 4 Owner 4. - Z&Ar Address <br /> Firm Partners, Addresses and Telephone Numb s <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title,. Date <br /> Please check Applicable Category(1-7) and Fill in th equiredyInformation <br /> 1. E] PUMPER VEHICLE PERMIT REGISTRATIO (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 x,34 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored t t <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name r �R-S:or-R.CE.No. <br /> Test Location ) V+�Test Date/Time ' <br /> 4. 11 SANITATION PERMIT I s 2 <br /> Job Address/Location r / <br /> Oi 1 Address <br /> Ol EPTIC TANK--0—CESSPOOLt LEACHING FIELD r❑=SEEPAGE-PIT- .❑_-PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER t <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 s <br /> Type Construction Disposal Site: <br /> No. of Units Equipment Stprage/Cleaning Location{s} �-----�-^_+ i Q <br /> 1 C <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 GLEANING, Chemicals Used/Amount/Mo. <br /> p I hereby certify that.l_have.prepare d.th is application and:that the work will be done in accordance with San Joaquin County r <br /> t ordinances, state l�ws,`and''rulbs and r Iatio s of-the•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 /> BILLING REMITTANCE $ REMIT <br /> BASE ,EXPLANATION AMOUNT DUE-1;� CHECKED <br /> •-I DATE DATE REMITTED - .d+•'- AMOUNT <br /> 1 :. . -.. <br /> FEE - <br /> LESS t <br /> PRORATION ley <br /> PLUS 1 " <br /> PENALTY <br /> OTHER <br /> OTHER_ . <br /> Received by Date Receipt No. Permit No Isoance Date Mailed Delivered <br /> ~ APPLICANT.—RETURN ALL COPIES TO7'ENVIRONMENTAL HEALTH PERMIT/SERVICES �1801 E.14A—MTON AVE.,P.O.Box 2009'�STOCKTON,CA 95201 <br />