Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> J. APPLICATION <br /> (For Non-Transferable, Revocable,and 5uspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Ahp re y ma to garry on sin s 'n the jurisdictional area of the Saoaqui` focal Health strict <br /> y Busine Address <br /> r - <br /> z Owner I Address <br /> R Firm Partners"f Addresses an Telephone Numbers af// <br /> 0. Business Telephone No. 33 Emergency Telephone No.�� +- <br />�Contractor Licence No. r 7 <br /> a �l' teK, Title , l9C.V� Date G_2 fix. <br /> LApplicants Name (Print) <br /> Please check,lApplicable Category (1-7) and Fill in the Required.Information 1 ! <br /> 1. 1:1 PUMP' VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites �•J <br /> Description(Make/Yr., Color) <br /> Serial No. <br /> 01 CAL. License No. CAL. License Renewal No. <br /> Capacity rip. Gal.,Weights &Measures No. Y <br /> P Y II <br /> Equipment Parking Address + <br /> 2. ❑ PUMPER YARD 4 <br /> For July 1, `I June 30, 19 <br /> ,II, <br /> No. of Vehides Stored <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST <br /> R.S. or R.C.Ec Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. E SANITATION PERMIT <br /> 1ik� & <br /> Job AddrP- <br /> .i. ANK <br /> kocation i <br /> O�w�er Address <br /> L'�SEPT 13 CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT El PACKAGE PLANT '1 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 9 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Const uction Disposal Site <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Unitsl <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified i! <br /> Operator Name i <br /> Plant Location <br /> '!E No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 d <br />'i SIZE: ❑'Less Than 1,000 Sq. Ft., ❑ More Than 1,040 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> II <br /> ' I <br /> it <br /> I hereby certify 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 regulati s of t e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I FOR DEPARTMENT USE ONLY <br /> Fee 131 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED ' i <br /> :�. BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE i <br /> LESS <br /> I <br /> PRORATION <br /> PLUS NI I <br /> PENALTY <br /> IP <br /> OTHER i <br /> „h I <br /> OTHER <br /> „I 3(z) �- <br /> s Permit No. IS ance ate Mailed Delivered , <br /> p - Received by Date Receipt No- <br /> ` APP — <br /> LICANTRETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.box 2009 STOGKTON,CA 95201 <br />