Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> rG0 (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ,Application is e b de tD ca'r brsin in the jurisdictional area of the San Joaquin olth District <br /> N Business Na D8A) <br /> 9 ` ddress <br /> z Owner C Address <br /> Q <br /> J Firm Partners, Addresses and T hone umbe s Qb <br /> Q. Business Telephone No. ` Emergency Telephone No. <br /> Contractor Licence No. Y <br /> Applicants Name (Print) - %� Title 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) __ y <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 *w - R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. (SANITATION PERMIT <br /> Job Address/Lo ation l S�� �.-ff• �"r� / ����� ' <br /> Owner _ Addres�sy <br /> El SEPTIC TANK 11 CESSPOOL T 1- <br /> LEACHING FIELD /+�-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY .❑ NEW P4.LREPAIR ❑ OTHER _ <br /> 5. ❑ CHEMICAL TOILETS ,For July 1, -June 30, 19 3 S <br /> Type Construction 's N Disposal Site,-_, <br /> �EquipmeSy t�o ge�Cleaning LOC tions) y �F <br /> t Ci <br /> ! 6. 11 PACKAGE TREATMENT PLANT For July 1,-June 30, 19� <br /> Operator Name „w.. r Where Certified <br /> CT <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 1,000Gq."Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> l <br /> I hereby certify that I have prep is plicati and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r s a e atio the San oaquin al Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING 1 REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE. DATE REMITTED AMOUNT <br /> IF <br /> FEE <br /> LESS <br /> PRORAT;ON ) — <br /> PLUS <br /> PENALTY �7 <br /> OTHER L <br /> OTHER <br /> Received by T Date Receipt No. Permit No, ssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES s" 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />