Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TheApplication. <br /> APPLICATION 4(400 10; 00 <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> x LIQUID WASTE <br /> Application ' hereb ade to car o usiness in the jurisdictional area of the San Joaquin Local Hea D)' r' <br /> HBusiness Name (DBA) Address 4�0' _L-n� <br /> z Owner Address <br /> 2 Firm Partn s, dresses and Telephone zu—rxlrs <br /> a. Business Telephone No. Emergency Telephone No. Ob <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date 4 <br /> Please check Applicable Category (t=7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) sr <br /> For July 1, June 30, 19 7+.y Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. License Rericwat No. <br /> Capacity _ Gal., Weights & Measures No. <br /> Equipment Parking Address "? <br /> 2. ❑ PUMPER YARD <br /> For July 1, . June 30, 19 �y - <br /> No. of Vehicles Stored - <br /> I <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST s <br /> R.S. or R.C.E. Name "" R.S. or R.C.E. No. <br /> Test Location y J _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT a17z ., Ile <br /> Job Addre Loc t' n , <br /> Owner Address <br /> )&SEPTIC TANK ❑ CESSPOOL -LEACHING FIELD SEEPAGE PIT , 11 PACKAGE PLANT - <br /> ❑ PERMANENT E] TEMPORARY El NEW REPAIR y ❑+OTHER !! <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 `�V �� { `L <br /> Type Construction Disposal Site l to <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 4 1' Where Certified <br /> Plant Location ' r f <br /> No. Units Served <br /> Plant Capacity - <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. lI <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 regulationa 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 JWy 31 <br /> BILLING REMITTANCE $ REMIT <br /> . BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> AMOUNT DUE CHECKED <br /> FEESI <br /> LESS <br /> PRORATION (, <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Ci <br /> Received by Date Receipt No, Permit No. lsst.ancel Date Mail Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />