Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign h Application. <br /> APPLICATION P <br /> (For Non-Transferible, Revocable,and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application isWebyaarry on bu§j&ess int a jurisdictional area of the San Joaq "n Loca ealth Dist ict,Business ame (DBA) tI7[� 1 r Addres Jr (a Owner Address rt aFirm Partners, Add sses anbers <br /> aBusiness Telephone No. Emergency Telephone No... <br /> Contractor Licence No. <br /> �Applicants Name (Print) Title o vi ie r - Date <br /> Please check Applicable Category(1- and Fill in 1111 Required Information w <br /> i. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) f + <br /> For July 1; June 30, 19 - 'Disposal Sites -- <br /> Description(Make/Yr., Color) <br /> 'x <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 Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERIIi�IT <br /> Job Addres /LocatioNcjhoK 9d l s-C <br /> Owner Address <br /> ❑ SEPTIC TANK ElCESSPOOL 13 LEACHING FIELD SEEPAGE PIT ❑ PACKAG PLANT �5 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 A 'V <br /> Type ConstructionDisposal Site e <br /> No. of Units - Equipment Storage/Cleaning Location(s) � <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> al <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. ,o <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home ow twor A tyddaswoese if seak4arring:,Icert rthatitttfte <br /> in such mAnneras;to 1 me s4*1 to worftman's camper"kn lasts of Cil ' rola" Pe►fornlaFnef ftV*rkfW wM6 thfs permit is issved.I shall notemploy any person <br /> comrammr"s ar*OvwmwtMB tae avid ids tf* <br /> 0121100Y Paas su6leef ta workttlan`s compensr t lows*,Calitornla, O ' sertffy the In the peftorrt&M 0the work for whin this permit is iss ,I shall <br /> I hereby certify that I have prepared tt plicatio and�t t the work will be done in'accordance with San Joaquin County <br /> ordinances, state laws, and rules a d'r`egul ons the Sa Joaquin Local Health District. <br /> It <br /> APPLICANT'S SIGNATURE X ' <br /> F <br /> I <br /> FOR DEPARTMENT USE ONL - 4. w <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 <br /> 119, <br /> LESS <br /> PRORATION <br /> PLUS Ai <br /> PENALTY <br /> f- { <br /> OTHER <br /> y OTHER <br /> r i <br /> Received by D to Receipt No. - Permit No. , Issuance Date , Maited Delivered - <br /> APPLICANT—AETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 } <br />