Laserfiche WebLink
APPLICATION <br /> ,[ `p, Non-Transferable, P,evocable,and Suspendabl�' ) SEPTAGc <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h by made to car business in the jurisdictional area of t�lSan Joaquin LoSpl Health District <br /> i r, Business Name (DBA) Address <br /> z Owner Address <br /> Firm Partners, Addresses and Tele nee Numbers <br /> a' <br /> Business Telephone No. 6 C1646I7 Emergency Telephone No. <br /> Contractor Licence No. <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 /> ) <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 /> FEquipment Parking Address <br /> .2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> FNo. 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 /> I Test cation Test Date/Time <br /> 1 4. qq SANITATION PERMIT <br /> Job Addre Location ~—�{! <br /> owner Address <br /> 4Q SEPTIC TANK ❑ CESSPOOL $LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY )Z NEW ❑ REPAIR ❑ OTHER <br /> F, 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <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 11,000 Sq. Ft. I <br /> !� ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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,rules and regul tions of a an Joaquin Local Health District. <br /> F APPLICANT'S SIGNATURE X <br /> F! <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> F BASE EXPLANATION AMOUNT DUE CHECKED <br /> . .DATE DATE REMITTED AMOUNT <br /> FEELESS <br /> I PRORATION <br /> 1. I <br /> PLUS <br /> PENALTY IG <br /> OTHER ) <br /> OTHER , <br /> 1 Received by Date Receipt No. Permit No. Iswa abate <br /> Mailed Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 76o1 E.HAZELTON A ., .Box 2009 STOCKTON,CA 952x1 <br />