Laserfiche WebLink
s .- <br />' Applications Will Be Processed When Submitted Properly Completea. <br /> APPLICATION / <br /> (For Non-Transferable, Revocable,and Suspendable) G SEPTAGE <br /> ENVIRONMENTAL L Ii E <br /> AL <br /> TH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) 7-0e- e-r`'al✓ Address <br /> Address <br /> QOwner <br /> f Firm Partners, Addresses and Telephone Numbers- <br /> -a19 Emergency Telephone No. <br /> a Business Telephone No. <br /> c /5-3 '� <br /> Contractor Licence No. Title dN�� Date ` ^g� <br /> LApplicants Name (Print) <br /> O <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) CAL, License Renewal No. <br /> l . Serial No. CAL. License 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 R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> E <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT Ta <br /> Job Address/Location -3.5-f/ <br /> �llti IBA i2 Llys Address ��r -cz-_ r�^2Id .5 �✓ <br /> j Owner I� SEEPAGE PIT ❑ PACKAGE PLANT 'j� <br /> 0 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Imo` <br /> REPAIRCR'OTHER <br /> I ,gI PERMANENT ❑ TEMPORARY 13 NEW <br /> k <br /> 5. 1:1 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 Where Certified <br /> Operator Name <br /> Plant Location - <br /> No. Units Served <br /> Plant Capacity <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 ertif 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 &Received By January 31 ❑.July 1 &Receiveo Byl July 31 <br /> REM <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE Y S <br /> t LESS <br /> r PRORATION <br /> PLUS <br /> I. PENALTY `+ <br /> OTHER v` <br /> OTHER -- (Y�. <br /> 1 a 3 <br /> Received by Date <br /> Receipt No. Permit No. ssuance to aile Delivered <br /> 1607 E.HAZELTON AVE.,A.O.hoc 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />