Laserfiche WebLink
/ pplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> AIA (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Address I <br /> aOwner Address <br /> J Firm Partners. Addresses and Telephone Numbers i <br /> aBusiness Telephone No., Emergency Telephone No, <br /> Contractor Licence No. <br /> L Applicants Name (Print) a w eZ = Title-' _ Date �' I <br /> Please check Applicable Category(1-7)and fill In the Required Information I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I l <br /> For July 1, June 30, 19 Disposal Sites W r <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 " 4 -• "f 'i'` <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ' <br /> No.,of,Vehicles Stored 4 ,1 <br /> No. of Chemical Toilets Stored- <br /> 3. ❑'PERCOLATIOWIT EST�"' <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location, Test Date/Time <br /> 4. Q� SANITATIONPER T ZI Z `^ ""�`- `- '_'."" •.�. --.. <br /> Job Addocation O� (� j� ® �( O� <br /> Ownerre X&NO Z-- Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD J61SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY QI-NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL:TOILETS For July 1,-June 30, 19 't <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 r l <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.,` ElMore Than 1,000 Sq. Ft. <br /> 0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ,.T' q r� <br /> z <br /> I hereby certify that I"have prepared this,applicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, arld rules andre ula " " s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE— <br /> FOR DEPARTMENT USE ONLY <br /> FPe f5 Due: ❑ ANNUALLY --...._❑ PER UNI ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jul 1 &Received B Jul 1 <br /> Y Y Y3 <br /> rBILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> GATE Rr DATE REMITTED AMOUNT <br /> FEE . <br /> LESS <br /> PRORATION [J <br /> PLUS 775 NO- <br /> PENALTY <br /> -PENALTY - <br /> OTHER a <br /> OTHER <br /> Yb <br /> Received by Dat x '� 'Receipt No. Permit No., Issuance Dat Mailed Delivered <br /> APPLICANT—RE7LRN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -' - 1601 E.HAZELTON .Box 2009 STOCKTON,CA 952D1 <br />