Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSure Iosign IneAPPucauVrI. <br /> APPLICATION <br /> (For Non-Transferable, Revocable',`and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District #, - <br /> mBusiness Name (DBA) - Address _ <br /> z Owner Address <br /> P. <br /> Firm Partners, Addresses and Telephone Numbers �� 7 <br /> CL Business Telephone No. - Emergency Telephone No. <br /> a _ <br /> 1 Contractor Licence No. h '" <br /> T �? Ni r'17 n _. Title Date - f <br /> Applicants Name (Print) _ — <br /> Please check Applicable Category (1-7)and Fill in the Required-InformationI <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t1 <br /> For July 1- June 30, 19 - — _ =Disposal Sites-_ — <br /> Description(Make/Yr., Color) <br /> Serial No. <br /> CAL. License No. CAL. License Renewal No. <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 e <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. No. <br /> R.S. or R,C.E. Name <br /> £ Test Date/Time <br /> Test Location - - <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address, a <br /> SEPTIC TANK ❑ ESSPOOL G❑'LEACHING FIELD -0 SEEPAGE PIT C1PACKAGE PLANT' <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ' 0 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction' {e Disp sal Site <br /> No. of Units Equipment Storage/Gleaning:Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location o -` � - <br /> �- No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 w <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,: ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.'<. <br /> i <br /> I here by�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 ules and regul" ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ". <br /> -.r►;r , x .,. FOR DEPARTMENT USE-ONLY <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. 0 July 1 &"Receivd By REMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE •5 AMOUNT DUE CHECKED <br /> DATE DATE =HEMITTED AMOUNT <br /> FEE' <br /> LESS <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> OTHER f _ y <br /> OTHER <br /> Date Y Receipt No. Permit No. I seance. ate Mailed 6elivered <br /> Received by _ - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM4TISERVICES 1641 E.HAZELTON AVE.,P.O.80�2409 STOCKTON,CA 95201 <br />