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 carry on business in the jurisdictional area of the San Jo_a_quin Local Health District <br /> Business � (`�D' )B Add ess Q <br /> aXwner ' ��� _.— Add ress0. <br /> 1 Firm Partners, Addresses and I 'ho be <br /> aBusiness Telephone No. � M Emergency Telephone-No, <br /> Contractor Licence No. <br /> a _ , <br /> L Applicants Name (Print, `Title; Date <br /> Please check Applicable Category (1-7)-and,Fill in'the Required Informatian,, <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 r <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored -10 <br /> 1 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?�QWITATION PER T 1 <br /> Job Addre ocatio � ' <br /> Ow ,,�� � Address ' <br /> SEPTIC TANK 13,CESSPOOL -Q-r ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER ` <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 e Y <br /> Type Construction Risposal'Site <br /> No. of Units a H.S_ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -.June 30, 19 ,r <br /> r Operator Name -Where Certified <br /> Plant Location <br /> Plant Capacity t No. Units Served f r <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 av prepared this L�, n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, hd les and.reguI tihe San Joaquin Local Health District. <br /> APPL'ICANT'S SIGNATURE s v <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 AMOVNT DUE CHECKED <br /> a <br /> DATE- ', --DATE REMITTED AMOUNT <br /> FEE <br /> LESS s <br /> 1 PRORATION 1 - - :' • - - , <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t E <br /> t , <br /> R wed by 'Date Receipt No. Permit No. Issuance Dale Mailed Delivered _ <br /> PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />