Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> • f (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hejepyymade to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F_ <br /> Business Name (DBA) r`�-�=���/,Ie_�"� Address „L 'L S� �"� <br /> i Owner - u iriC�Yl Address C <br /> a <br /> j Firm Partners, Addresses and Telephone N mbers <br /> aBusiness Telephone No. (� �gg- Emergency Telephone No. <br /> Contractor Licence No. <br /> L 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 /> 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. of Vehicles Stored <br /> No. of heroical Toilets Stored <br /> 3. XERCOLATION TEST <br /> R.S. or R.C.E. Name r7 ei/� trtJ R.S. or R.C.E. No. ;2 �.2� sS <br /> Test Location VcL eco d' Test Date/Time SC4 <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 applicat' an that the work 1 a done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatio th J aqui Lo al ealth 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 $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �/ AMOUNT <br /> FEE O ! 1L A? /4f /5* ry /7 le '/ 9 <br /> LESS <br /> PRORATION #'� 211, :z 2, # 3 2-1 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S <br /> ved 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.Box 2009 STOCKTON,CA 95201 <br />