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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby mad to carry,on_ siness in the juri dictional area of the,Sjjn Joaquin Local Health istrict <br /> H Business Name BA) " Address 62r4 <br /> Owner t- Address 51r��7 <br /> �irm Partners, Addresses and Telephone Numb rs <br /> L3usiness Telephone No. 9 j M O S Emergency Telephone No. <br /> Contractor Licence No. 6 �1 <br /> 4pplicants Name (Print) Title Date <br /> Tease check Applicable Category(1-7)and Fill in the Requi ed Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> mor July 1, June 30, 19 Disposal Sites _ <br /> description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic.7:nse Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> quipment Parking Address <br /> t. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> Vo. of Vehicles Stored _ <br /> Vo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> 4.S. or R.C.E. Name R.S. or R.C.E. No. <br /> lest Lt ion Test Date/Time _ <br /> 4. 9 SANITATION PERMIT <br /> Job Address/ ocation c't� <br /> s <br /> Dwner Address d <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ,SE AGE PIT ❑ PACKAGE PLANT U`) <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER .--D <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 12� <br /> Type Construction Disposal Site QI <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 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I 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 rujo and regulations f t'e San Joaquin Local 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 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> — — BASE EXPLANATION DATE DATE REMITTEDfAMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />