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 /> Applicat' is ereby e t rry on business in the jurisdictional area of the San Joaqurin He h st <br /> HBusiness me (DBA Addres �5 Lo t <br /> z Owner Address S <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 3 t t r <br /> Id� <br /> Applicants Name (Print) Title Date Q <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) I <br /> Serial No. r CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br />` Equipment Parking Address -- <br /> E 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 -i <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 'a <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 110 10 <br /> Job Address cation <br /> Owner t ` Address <br /> ❑ SEPTIC TANK ❑ CESSP OL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN <br /> /DCPERMANENT ❑ TEMPORARY LJ NEW REPAIR FOTHER <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 /> 6. ❑ PACKAGE TREATMENT PLANT Foir 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 <br /> Y i <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 r and regulations the S Joaquin Local Health District. C,(� <br /> P <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ) <br />{ Fee IS Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jan r1 ❑ July 1 &Received By July 31 <br /> REMIT 1 <br /> BILLING REMITTANCE $ i <br /> BASE EXPLANATION _ DATE DATE RE T D AMOUNT DUE CHECKED <br /> 1. AMOUNT <br /> FEE <br /> LESS <br /> PRORATION "- <br /> I <br /> PLUS <br /> PENALTY 11 <br /> OTHER <br /> F <br /> OTHER i <br /> i. /00001r^ -Received by Date Receipt No. Permit No. Issu rice Date Mailed Delivered - <br /> APPLICANT—RETURN ALL CO IES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />