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) 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 /> yBusiness N me (DBA) Address <br /> a0...... 4a IV I Address )• 4:"! t. V- O 1 [)I. <br /> Firm Partners, Addresses and,T/elgph ne Nu bers <br /> aBusiness Telephone No. �X 7 Emergency Telephone No. 7 /4/-, <br /> Contractor Licence No. <br /> L Applicants Name (Print) c N q +,t A? It Title 0 I'L A '!E! r Date <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) <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 /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 1$ SANITATION PERMIT <br /> Job Address/Location ( i FFr <br /> Owner J, C Ka a G Y' Address •� AJ <br /> SEPTIC TANK ❑ CESSPOOL M LEACHING FIELD P.SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 19 NEW ❑ REPAIR ❑ OTHER .v <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 A <br /> Type Construction Disposal Site 1 <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 <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 r Iles and regulatI s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X o" <br /> D'r <br /> 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> (� AMOUNT <br /> FEE 44—S <br /> Ej <br /> CESS <br /> PRORATION ' i 6 <br /> PLUS '0 <br /> PENALTY r <br /> OTHER <br /> OTHER <br /> Received by I D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA.95201 <br />