Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> s,. (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE w <br /> Applic n is Vregby m e to carry o usin s' th }urisdictional area of the�n Joaq Locai,H/� Ith.D.isst 'ct r <br /> m Busin ame (DB r Address J�!Q <br /> aOwn Address <br /> J Firm Partners, Addresses and ele on umbers ` <br /> M Business Telephone No. "` Emergency Telephone No. <br /> Contractor Licence No. <br /> m Title _ G Date-�10 e Z <br /> a Applicants Name (Print) <br /> -Please check Applicable•Ca ory(1-7) and Fill in a Required Information . <br /> 1:❑ •PUMRER-VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C <br /> For July 1, Jurie 30;19` Disposal Sites <br /> Desc ri pti orr(Make/Y r;-Color} <br /> ..,�. <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 /> r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored '- <br /> No'of Chemical Toilets Stored <br /> 3. CD PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E.No. <br /> Test'Location — � r Test Date/Time <br /> 4. ❑ SANITATION PER IT <br /> F � , t <br /> . Job Addre0P/Localtion �� <br /> Oww�r<% Address 1 <br /> Fsw PTIC TANK ❑ CESSPOOL LEACHING FIELD �EEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ' Z"NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> i <br /> Type Construction Disposal Site <br />� v- <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 .4" <br /> 11 <br /> } -- - - , <br /> -operator Name ----� � F:: - - .Where Certified <br /> Plant Location �- <br /> s T <br /> P,)ant Capalcityc7# No. Units Servedf <br /> 7? 1�� LAUNDRY For July#1,; June 30, 19 l i .LLQ , <br /> SIZE: C] Less Than 1,000 Sqr Ft., ❑ More Than 1,000 Sq._Fi.y • <br /> DRY CLEANING, Chemicals Used/Amount/Mo..- '� rT <br /> H°mea�w+►aror Weir['sa�0 tli ethwi 1p;-fC13rfifttthafllrtbeperwmanceoftheworklorwhichthispermit sissued.lshall riot employ any person <br /> r In Such MrIflerast*b6C8 .Subjecrt0workntan'scempensafidtriawsctca famia.'• <br /> r. 'Co+tiwn tz a f+ D a' ati sl ►iaR e0tieai the fo"I"I "t certify that M the perforloance of the for which this permit is issued,i shall <br /> I !�persot�'stlt�t tttttltfiklffalf`l�itppdttlilllarlrs of CaCiftNniz" <br /> c I <br /> I'hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i^ ordinances, state laws, an ules.anrd r,?IatWhs,.of th 4 San Joaquin Local Health District. <br /> IfAPPLICANT;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 &;Received By July 31 <br /> - i - BILLING REMITTANCE - $ REMIT <br /> C _ <br /> BASE s EXPLANATION AMOUNT DUE CHECKED <br /> 3 DATE DATE — .REMITTED AMOUNT <br /> FEE c r <br /> I LESS <br /> rPRORATION" �- -. �..r - `#.- '^:• _'. <br /> E PLUS <br /> PENALTY <br /> OTHER <br /> .q. <br /> OTHER �..r..fi. —.t �..� <br /> Receivedlby - Date Receipt No Permit No. I suance ate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E:'HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />