Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureTo 51gn IneAppucauvn <br /> APPLICATION <br /> _ : -(For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Appl!catipn is h reby ade o carryon business in the jurisdictional area of the San Joaquin Local Health District; <br /> Business Name (DBA) Address,� .. <br /> a Owner. <br /> Address - <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.. C\3 .. oZ(o.�. Emergency Telephone No. <br /> -i Contractor Licence No. <br /> LApplicanis Name (Print) �r--t� -Yi13 _ s Title i Y Date v <br /> Please check Applicable Category(1-7)and'Fill In the Required ylnformation .F <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> -j: Disposal Sites-- -' <br /> For July 1,= June 30,19-__y- - - <br /> a <br /> Description(Make/Yr., Color) - CAL. License Renewal.NO. <br /> Serial No. 4. CAL. License No. <br /> Capacity Gar.,Weights &Measures No. } <br /> t <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. No. <br /> R.S.or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location kzolt NX <br /> o ` Y Address <br /> Owner rV <br /> 11 PACKAGE PLANT <br /> C1 ❑ <br /> SEPTIC TANK ❑ CESSPOOL � rLEACHING FIELD SEEPAGE PIT <br /> ❑ PERMANENT . ❑ TEMPORARY E.NEW A 13 REPAIR l <br /> 5. 11 CHEMICAL TOILETS- For July 1, '-June 30, 19 <br /> Type Construction <br /> f' Disposal Site <br /> No, of Units Equipment Storage/Cleaning Locations) _ <br /> 4 � <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7: El 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 /> t ' <br /> I hereby-certify that l have prepared this application and that,the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE �r V�`_ 4 � <br /> Fee <br /> FOR DEPARTMENT.USE ONLXae: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑InLA-v &Received By'January 31, <br /> July 1 &Received By July 31 <br /> REMIT <br /> T BILLING REMITTCvE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE — DATE - =REMITTED.- AMOUNT" <br /> {� <br /> FEE <br /> LESSE <br /> PRORATION <br /> PLUS <br /> PENALTY 'µ <br /> k <br /> OTHER, . <br /> '. OTHER <br /> r <br /> 1D 1 . ' <br /> Received by Date - Receipt No. Permit No <br /> Issuance Date Mailed Dea:�ered - <br /> STOCKTON,CA 95241 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O"Box 2009 <br />