Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> o� APPLICATION (/lJ� D <br /> (For Non-Transferable,'Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> j LIQUID WASTE <br /> Application is herebymadeto carry on bus i ss in the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness Name (DBA) !'- �- �C� ��-�,? �k Y_�1-[, Address �- <br /> �FF. ,t <br /> a�Owner� �.�"��.��- _._ Address. <br /> Firm Partners, Addresses an T le hone Numbe <br /> d Business Telephone No. �- Emergency Telephone No..., . <br /> Contractor Licence No. Q <br /> Applicants Name (Print) Title �� ate r <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPEWVEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) or <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 <br /> easures-No----Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> June 30,"19---- <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E.NameR.S.or R.C.E. No. <br /> t <br /> Test Location Test Date/Time ' <br /> 4. ❑ SANITATION PER_ T <br /> Job Addre_ /Location <br /> = .- <br /> Owner T'_i =lam Address. <br /> ❑ SEPTIC TANK El CESSPOOL LEACHING FIELD fEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERM_ANENT ❑ TEMPORARY 11 NEW C1OTHER <br /> 5. 11CHEMICAL TOILETS For July 1, -June 30, 19 �;EPATI� <br /> t <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/C leaning,Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name F•- - Where Certified f <br /> Plant Location <br /> Plant Capacity No. Units Served T - <br /> 7. ❑ LAUNDRY For July 1, -'June 30, 19 ) I t <br /> SIZE: 0 Less Than 1,000 Sq: Ft., ❑ More Than 1,000 Sq. Ft. ; ! <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certifythat I`have�prepared this ta_ps llicati and that th I ark will be done in accordance with San Joaquin County <br /> ff} ordinances state laws, 4d rutes and regu a onsbFath. .Sa Joaq In Local °eal h District. <br /> APPLICA'NT'S SIGNATURE \' n <br /> I t <br /> FOR DEPARTMENT USE ONLY <br /> Fees IS Due: ❑ ANNUALLY ❑ PER UNIT 11 PER SITE ❑ EACH ❑ Jan ry 1 t'veBy January 31 ❑ July 1 &Received By July 31 <br /> t BILLING REMITTANC $ REMIT <br /> ' f BASE EXPLANATION - AMOUNT DUE CHECKED <br /> I DATE TE REMITTED AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION <br /> PLUS } <br /> PENALTY - <br /> OTHER <br /> a <br /> OTHER <br /> Received by I Dat Receipt No. Permit No. Issuance Date Mailed � Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br /> i <br />