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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE i <br /> Application ' hereby made o car on bus' ess i the jurisdictional area of the Sa Joaqui_Q Local Health District <br /> i ,F Business Nam (DBA) Address Q 111 <br /> P_ Owner Address <br /> j' J Firm Partners, Addresses and Telephone Ngbers <br /> aBusiness Telephone No. — 3 J-►IDS' – _- Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) 4- Title � Date a <br /> Please check ApplicableCategory(1-7)and twill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. 71 CAL:License No. —CAL-.=Licc:�se-Renewal-No: <br /> CapacityGal.,-Weights & Measures No.. f <br /> Equipment Parking Address ti <br /> 2. ❑ PUMPER YARD <br /> For July 1, ` June 30, 19 <br /> No. of Vehicles Stored i <br /> No. of Chemical Toilets Stored _ <br /> 3. ❑ PERCOLATION TEST; <br /> y R.S. or R.C.E. Name R.S.or R.C,E: No. _ <br /> Test L anon Test Date/Time <br /> 4. SANITATION PERMI=" O <br /> Job Addre Location 1;47 AA <br /> Owner ' + _'} =1 Address O f <br /> ❑ SEPTIC TANKS[IXESSPOOL "�iO LEACHING FIELD li'SEEPAGE PIT ❑ PACKAGE PLANT s <br /> ❑ PERMANENT "' D TEMPORARY ❑INEWIJ-'�-0 �EPAIR ❑ OTHER �r <br /> 5. t] 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 x <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. rx t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> A <br /> I hereby 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 rules an egulations of the SWUJslaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � ((� <br /> it 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 AMOUNT DUE CHECKED <br /> -( DATE DATE REMITTED AMOUNT <br /> { <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY t <br /> OTHER <br /> OTHER <br /> 1 r ?� <br /> Received by Date Receipt No. Permit No. Issuance Dale. Mailed Delivered'" <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.H#ZELTPN AVE.,P.O.Box 2009 STOCKTON,CA 9 201 <br />