Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, 8 ocable,'and Suspendable) SEPTAGF <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Appi ication is he by made to carry on business in the jurisdictional area of the San Joaquin Local Health district <br /> ,;,Business Name (DBA). Y Address y <br /> i Owner _ �• L� Address _ _ - <br /> a <br /> u,Firm Partners,Addresses and Telephone Numbers - <br /> e Business Telephone No. Emergency Telephone No- h <br /> Contractor Licence No. _ 4 <br /> Applicants Name(Print) �"r Title DateWIJ j <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(MakeNr.,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 /> I No.of Vehicles Stored �.. <br /> No. of Chemical Toilets Stored __.-. w- 4r, ! - <br /> 3. ❑ PERCOLATION TEST s <br /> R.S.or R.C.E.'Name - R.S.or R.C.E. No. . <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT _ I <br /> Job AddreWLdcation <br /> Ow (, .97s /ylr6 SST' Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT Q PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER �Al <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19-- <br /> Type Construction Disposal Site ' <br /> No.of Units Equipmen-Storage/Cleaning L•ocation(s) <br /> E .- ... <br /> + S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> I - <br /> Operator Name Where Certified <br /> Plant Location <br /> _�" t <br /> Plant Capacity ""NoLl�lits 5er�ed �. r <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 • , a e <br /> t SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1000 Sq. Ft-« t - <br /> ❑ DRY CLEANING,Chemicals LlsedlAmount/Mo. t <br /> tt <br /> i A-. <br /> I hereby certify that 1 have prepared'•t ils 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)( - - - <br /> t <br /> ,-FOR DEPARTMENT USE ONLY <br /> Fee Is bue:❑ ANNUALLY ❑ PER UNIT, ❑ PER 51TE 7.+ ❑-EACH- ❑ January 1 &Received By January31 ❑ July 1&Received By July 31 <br /> y r.[_ — --. I REMIT <br /> ; BILLINI3 REMITTANCE, 3 AMOUNT DUE CHECKED <br /> EASE EXPLANATION <br /> - 1 DATE DATe•• REMITTED\ t AMOUNT <br /> FEE <br /> PRORATION f y <br /> PLUS <br /> PENALTY •r =1 •'b +� <br /> OTHER <br /> Receiued by Dale Re"ivt No, Permit No. luam�e uaw !Mailed, 06yered <br /> APPLICANT•--RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 — <br />