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 i eby rnade topl-06,0 <br /> ry orkbu Ines In the jurisdictional area of the San Joaquin Local ith Disttriic�t <br /> r Business Name BA) r Address 1� �s z <br /> z Owner k14 41 Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ^Z <br /> L Applicants Name (Print) `"F L Titled Date ' <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. I ' <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 L ation Test Date/Time <br /> 4 SANITATION PERMIT <br /> Job Address/Location , .:Els�ch f',T •_1Cx•!4ld� ' _ - /`f r� ©S' `-' <br /> Owner •�`'' Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL MCLEACHING FIELD $SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑"NEW EPAIR ❑ 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, -June 30, 19 <br /> Operator Name Where Certified 90 <br /> Plant Location \1, L <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 �' 03 <br /> SIZE; ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> .y <br /> I hereby certify that I have p a d this a licati . and that th ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, and I d re alio 11e San Jo m Loci ealth Dist. �. <br /> APPLICANTS SIGNATURE. <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 DATE . DATE R ITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS f <br /> PRORATION <br /> PLUS <br /> PENALTY !/(/ <br /> s • <br /> OTHER <br /> OTHER <br /> l 113 -7 t + 7 <br /> d by Date Receipt No. Permit No. Issua ce D to Mailed Delivered <br /> t. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br />