Laserfiche WebLink
Applications Will Be Processed When Submitted Properlycompieiea. ow owl ­v- <br /> APPLICATION <br /> vAPPLICATION <br /> ` (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> A tion is hereby made It rry on business in the jurisdictional area of <br /> the San Joaquin Local Health District , <br /> Addre <br /> yBusiness A) <br /> aOwner ddress <br /> J Firm Partners, Addresses and Telephone Nulr)bers _ r z;/i : "-''�j <br /> rt 7 Emergency Telephone No. <br /> a Business Telephone No. `] <br /> a - <br /> Contractor Licence No. Title Date �^1� <br /> Applicants Name (Print) t� <br /> Please check Applicable Category (1-7 and Fill in the Required Information d <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I r <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. Lic"Ise Renewal No. <br /> Serial No. CAL. License No. ` <br /> Gal.,Weights &Measures No. <br /> Capacity <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 Test Date/Time <br /> Test Location 7 <br /> q, lLl SANITATIO PERMIT „�¢J <br /> Job Address 0 <br /> Owner Address <br /> Ia�EACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> L•l SEPT IG TANK CESSPOOL ❑ REPAIR 1:1 OTHER _ A <br /> ®"rERMANENT ❑ TEMPORARY �EW W <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 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., <br /> ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared t plicati n and t at the work �b?done in accordance with San Joaquin County <br /> ordinances, state laws, and rule a ulatio s t Joaquin a District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> PER UNIT © PER SITE El EACH ❑ January 1 &Received By January 31 El July 1 &ReceivedJuly 31 <br /> Fee Is Due: ❑ ANNUALLY REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION ry/ <br /> PLUS W <br /> PENALTY I <br /> OTHER [! <br /> OTHER <br /> eAPPby D e <br /> 01 <br /> LI <br /> Receipt No. Permit No. I nee ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZE ON AVE.,P.O.Box 2049 STOCKTON,CA 952 <br />