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 T <br /> Application is hereby made to carry on bus' s in theilq sdictional area of the San Joaquin Local Health District <br /> JAy Business Name (DBA) c- {�dress <br /> z Owner Address <br /> j Firm Partners, Addresses and elephon e Number : <br /> aBusiness Telephone No. `. Emergency Telephone No.,` <br /> Contractor Licence No.J j <br /> �Applicants�:l�iame(Print)x , Title ate <br /> ,a <br /> Please check Applicable Category (1-7)and Fill in-the Required Information- <br /> 1. C] PUMPER VEHICLE PERMITRE'GISTRATION (FOR EACH VEHICLE) <br /> � . tt <br /> For July 1, June 30, 19 t Disposal Sites <br /> Description(Make/Yr., Color) s , <br /> Serial No. CAL. License No. ' — — -AL.-License Renewal No. <br /> 'Capacity - -Gal.;Weights-&-Measures"lVo:' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ) <br /> ,Por$uly-1;June 30;•h9'r. <br /> No. of Vehicles Stored _ ! r <br /> No. of Chemical Toilets Stored 1 j <br /> 3. ❑ PERCOLATION TEST f <br /> R.S.or R.C.E. Name=--s� 4 R.S. or R.C.E. No. <br /> ' Test Date/Time <br /> Test"Location t _ , <br /> 4. SANITATION PER IT ! ` L_ ` "a -'• -+ -. <br /> Job Addre ation <br /> Owner n Address <br /> ❑ SEPTIC TANKI E] CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT f <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL`TOILETS For July 1,-June 30, 19 1 --- <br /> Type Construction t Disposal Site ---•--.�.---Pn= —— = y a t <br /> No. of Units ( I Equipment Storage/Cleaning Location(s) 1 <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f <br /> Operator Name I Where-tertified. i <br /> Plant Location <br /> Plant Capacity No.,Units-Served e c <br /> 7. ❑ LAUNDRY f For July 1, -June 30, 19 `"- *""J <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,400 Sq. Ft. [ <br /> © DRY CLEANING, Chemicals Used/Amount/Mo. I l <br /> Home ownerar licensed agent's slgnatureceitifleatha following:1 certify that in the Performance of the Work f&; sBu <br /> in sock manner as to become subject to workman's compensatton laws of California.- ;"which iiia permit lS Issued,Isf+all not ern ployany parson T x - <br /> contrector's tiring nr sub.contrectinp aEgrelture eerlifies the totlowine: A certify that in the pertorma}1Co of the work for which tftl9 yermlt Is Issued,t shall <br /> employ persons subject to workman's compensation faros of Califoinia.' <br /> I hereby certify I have prep ed this ap lication and that the work will be done'iri accordance with San Joaquin County i 7 <br /> ordinances, law Ind rules d regula i ns of he S Joaquin Local Health District. <br /> f � � i a <br /> APPLICANT'S SIGNATURE , <br /> i ' s <br /> i. FOR DEPARTMENT USE ONLY j <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER'UNIT' ❑ PER_SITE ❑ EACH ❑ January 1 &Received By January 31 El 1 &Received By July 31 r 4 <br /> l ` REMIT ! <br /> r'�-"' 'r'r BILLING REMITTANCE -AMOUNT DUE CHE KED ; <br /> BASE EXPLANATION DATE DATE 'REMITTED <br /> YFEE L g <br /> r ► <br /> LESS <br /> PRORATION <br /> PLUSQDate <br /> PENALTYOTHERO7HERReceived byReceipt No. Permit No. - Issuance ate Mailed Delivered <br /> r <br /> APPLICANT-RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO „P.O.Box 2009 STOCKTON,CA 95201 „ <br />