Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appti <br /> APPLICATION <br /> (For Non-Transterable,-Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL_ HEALTH-PERMIT <br /> f <br /> I� LIQUID WASTE <br /> Application is rebpy,m�a'de 6t carry o business in the jurisdictional area of the an.J quin Local Health Dist�a�'w� <br />' rn Business Name (DBA) ' /+r.!- l�.�fJ�; � �- ICU 9S�4 <br /> Address�� !k!W,—��4�� f f <br /> z Owner r II ,_. �• Address --_ `.. „ <br /> 2 Firm Partners, Addresses and T ne Numbers <br /> aBusiness Telephone No. - .k. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) l� �� -T Title + Date <br /> Please check Applicable Category,(1-7)and Fill in the Required Information .� v , �£ .4 1� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) v t <br /> For July 1,- - - June 30,'19�M Disposal Sites <br /> Description(Make/Yr., Color) l� <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity I�� Gal., Weights &Measures NO. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I` <br /> 3. ❑ PERCOLATION TEST r' t ' F 1Y, ` <br /> R.S. or R.C.E. Name R.S. or-R.C:E. NO. t " <br /> Te Location Test Date/Time f' <br /> 4. SANITATION PERMIT �P <br /> -Job Addre /Location 762 7 E ///gig g � k14 PO <br /> Owner * Address • 00+ k +' <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 IM Equipment Storage/Cleaning Location(s) [ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name - �� Where Certified <br /> Plant Location IM <br /> Plant Capacity �M No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Jiune 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq.'Ft., _ ❑ More Than 1,000 Sq. Ft. ;! ` <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> A..'r <br /> F <br /> I hereby certify that. ave prepared this application and that.the work Will be done inaccordance with San Joaquin County <br /> ordinances, state lawsd?rul -nd regulati s f the oaqui Local Health District. <br /> op <br /> 'APPLICANT'S SIGNATURE X " f r j <br /> ol <br /> t i FOR DEPARTMENT USE ONLY <br /> ii <br /> FEE IS DUE: ❑ ANNUALLY El PER.UNIT; El PER SITE • EACH 11January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT _J <br /> BASED EXPLANATION BILLING ,REMITTANCE $ AMOUNT DUE CHECKED r <br /> DATE DATE- REMITTED - ANkUNT <br /> i <br /> FEE <br /> PRORATION <br /> 4 <br /> PLUS , <br /> PENALTY i f _f <br /> OTHER <br /> IIYI .. -�. e _ <br /> Iryl <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issuance Date v Mailed Delivered <br /> ""�` <br /> APPLICANT—' RET DRN ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009' 'STOCKTON,CA 95201..— '-'' <br />