Laserfiche WebLink
AF'F'L1l;A 1 IVN <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE. ' <br /> w ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to ca`r on business in a jurisdictional area of the San Joaquin Local Health D' trict 1 <br /> a Business Name (DBA) zxn-#,`kn PC{ �.�M�Q•�a�� Address- <br /> I.- <br /> ddress <br /> Owner_;. _A) Address -- ---- <br /> Firm Partners,Addresses and Telephone Numbers � � Z 2 <br /> 1L Business Telephone No. Emergency Telephone No. <br /> -i Contractor Licence No. <br /> L Applicants Name(Print) Title Date. <br /> Please check Applicable Category(1-7)and Fill In the Required InformaU n 1 1 <br /> } . <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 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.o Vehicles Stored <br /> o.9 Chemical Toilets Stored , <br /> 3 PERCOLATION TEST a 0 ram tt � OCA 10 .0 <br /> S.or R.C.E.Name J R.S.or R.C.E.No.. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 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 rules and regulations of the 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 d Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED <br /> REMITTED AMOUNT <br /> ll cc <br /> /0 <br /> FEE �iO(7 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .-Aecerved by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />