Laserfiche WebLink
-Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. F <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT } <br /> LIQUID WASTE <br /> Applicati ' hereby de t carry o business in the jurisdictional area of the Sf` Joaq In Local Health District <br /> FBusiness Name IDBA) WeCE-. Address` <br /> z Owner © Vzk e Address <br /> d <br /> zu Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. `f + <br /> LApplicants Name (Print k -�- Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information W <br /> 1. Cl 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 /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Y <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Lo ion Test Date/Time ? <br /> 4. U1 SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address G 1. <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> ' •5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 A <br /> _Type Construction Disposal Site a <br /> `.No. of +ts Equipment Storage/Cleaning Location(s) <br /> 6. UXPACKAGE 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 CLEANING, Chemicals Used/Amount/Mo. <br /> E <br /> I hereby certify that I have prepared this application and that the work be done in accordance with San Joaquin County <br /> ordinances, state laws, and r I and regulation of t S n 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 a <br /> - REMIT <br /> BASE EXPLANATION 'BILL-ING^-r REMITTANCE _ $ AMOUNT DUE CHECKED <br /> - DATE DATE - REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> i <br /> OTHER <br /> OTHER <br /> i <br /> Received by Date Receipt NO. Permit o IssManceflDtte Mai ed De ivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA.95201 - <br /> y+„4 <br />