Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> R (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE O ) <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name DBA) Address =1• Q/^f � <br /> 4 Owner Address „� _l�,1� �^�1 re I�QJ c� <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Emergency Telephone No. <br /> G. Business Telephone No. g y ) <br /> Contractor Licence No. ��1 �_,Applicants Name (Print) TitleDat ` { <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 /> s <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time N y <br /> 4. ❑ SANITATION PERMIT N <br /> Job Address/Locatio <br /> Owner Add res A <br /> xV <br /> SEPTIC 11 CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT OQ <br /> ❑ PERMANENT ❑ TEMPORARY EW Cl REPAIR ❑ OTHER <br /> / 3 <br /> 5. 11CHEMIC AL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locdton(s)� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> ' Where Certified 4 <br /> Operator Name 4 <br /> Plant Location Ilk <br /> Plant Capacity No. Units Served <br /> I _ <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 /> Aiyl <br /> At <br /> I hereby certify that I have p pared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re lotions o the Joaquin L �aleatthDistrlict/. , <br /> APPLICANT'S SIGNATURE X f _ <br /> t _ fi - <br /> . <br /> FOR DEPARTME_NT USE ONLY <br /> i _1..UFee Is Due: ❑-ANNUALLY f❑TER UNIT} PER SITE '-A`�❑ EACH ❑ Sanuary`1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r REMIT <br /> r N +T BILLING_ ,.. REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE ;, rAIATION `DATE DATE REMITTED <br /> AMOUNT <br /> FEE.. <br /> LESS <br /> PRORATION } <br /> PLUS li <br /> PENALTY <br /> I. <br /> OTHER <br /> r <br /> OTHER <br /> I ' <br /> Recefived by Dat Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />