Laserfiche WebLink
Applications Will Be Processed When Submitted Property Completed, Be Sure To Sign The Application <br /> APPLICATION <br /> - (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQU10 WASTE <br /> Application i reby made to arry on busin Ss in the ju-i di Tonal area of the �Joa uin Local Health Distri <br /> i Address <br /> ,Business Name (DB <br /> I.- <br /> Owner " - <br /> Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> R Business Telephone No.- Emergency Telephone No. <br /> Q d <br /> Contractor Licence No. <br /> Title Date <br /> L Applicants Name(Print) <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR,EACH VEHICLE) t <br /> t ' <br /> For July 1,"'^' June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity % ` '" 1 *-_Gal., Weights &Measures No. s y <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PE OLATION TEST R.S. or R.C.E. No. <br /> R.S. or .0 <br /> .E. Name t; ; <br /> Test cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> z J�6Go <br /> k Job Address/Location �PIT <br /> vdAddress VPE11RMANENT <br /> TIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAG ❑ PACK E PLANT <br /> t 11 TEMPORARY ❑ NEW ❑ REPAIR ,❑BOTH <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 3Q 19 i 1-. �1 <br /> Disposal Site <br /> t Type Construction y r N <br /> (� <br /> No. of Units Equipment Storage/Cleaning Location(s) .. <br /> 6. 11PACKAGE TREATMENTP j LANT 1 For July 1, -June 30, 19 Where Certified Clio <br /> Operator Name - -- - -- �..—,Y_. <br /> Plant Location <br /> L No. Units Served` <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 7r <br /> Q DRY CLEANING, Chemicals Used/Amount/Mp.y, , <br /> j -3 <br /> I hereby certify that I have prepared this,app�lication 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 DEPAR ENT S ONLY <br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE ❑ E El January 1 &Remved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE El(PLANATION BILLI MITTANCE $ AMOUNT DUE CHECKED <br /> D T DATE REMITTED AMOUNT <br /> q <br /> FEE <br /> �s <br /> s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _5 <br /> i Received by' <br /> Date Receipt No. Permit No. Istpuance vate Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMITISERYICES �/ 1�E�HAZELT N AVE•,P•O-Box 2009 STOCKTOH,CA 95201 <br />