Laserfiche WebLink
Applications Will Be Processed WhenSubmittedPropertyL.ompletca. <br /> APPLICATION <br /> (For Nan-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ca ion is he�ymde to carryon bu$ine in the juri dictional area of theeSal�.J�a uinq Loc-91 r lth t�i(DBA) ✓ ► t �I��` L L-- �Address�,�- —�—L <br /> L Address �-- A <br /> Irm Partners, Addresses and el phone umbers <br /> CL <br /> Business Telephone Na. Emergency Telephone No. r <br /> ContractorLicence No. Title L ate <br /> Applicants Narrie (Print} <br /> Please check Applicable Category(1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE.PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites �-- <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No, CAL. License 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 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 �S <br /> Owner Address <br /> 11 SEPTIC TANK 13 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 13TEMPORARY �NEWFIEPAIR 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction f <br /> No. of Units Equipment Storage/Cleaning Location(s) i f/), <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified+ -� <br /> Operator Name <br /> Plant Location <br /> No, Units Served <br /> Plant Capacity <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 /> I have�ules <br /> this-.a cation ad that the work will be done in accordance with San Joaquin County <br /> I hereby certify�t p in Health District. ~� <br /> ordinances, state law ano, are latio so t <br /> .• J� <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKELI <br /> BASE EXPLANATION DATE DATE REMITTED RMDUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS +/t3 <br /> ` PENALTY <br /> OTHER <br /> OTHER <br /> �Y1 �? 3a- <br /> 1 ate Receipt No.' Permit No <br /> Issuance Date Mailed Delivered <br /> Received by <br /> APPLICANT�RETUAN ALL GOPIES TO: ENVIRONMENTAL HEALTH PERMI7lSERVIGES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 8520 <br />