Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application., <br /> APPLICATION , <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio hereby made ca on business in a jurisdictional area of the a6n-J�oaqui jn Local Heeal�th�Distric <br /> yBusiness Name (DBA) �Il� }-� �J.___ � C.. Address <br /> cOwner Address <br /> J Firm Partners, Addresses and T lephone NGu�mbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) tv_- Z= Title Date <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) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 4 <br /> For July 1, ` June 30, 19 <br /> No. of Vehicles Stored} <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r" t Cl1 <br /> R.S. or R.C.E. Name; R.S. or R'C.E: No. <br /> Test L cation t Test Date/Time Q <br /> 4. SANITATION P MIT <br /> Job Address/Locationr <br /> Owner �iLD3fi1 ! -V L0�1:/�1l±AlrA- Address 11 )Is t7t <br /> SEPTIC TANK 110ESSPOOL 6Y LEACHING FIELD ❑ SEEPAGE PIT f3 PACKAGE PLANT..1 <br /> EWPERMANENT [TEMPORARY WNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 � <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) I �{ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name `-Where Ger#ifieo <br /> Plant Location <br /> Plant Capacity No. Units Served - t <br /> 7. ❑ LAUNDRY For July 1, -June 30,_19_ _ ... �_ R.. '..�_,. . Tz' (3`,J \ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,' ❑ More Than 11,000 Sq. Ft. <br /> s <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> VL <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 re ul ions/afi/t)1e n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 <br /> } FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE I: ❑ EACH ❑ January 1 &Received By Janu&ry 31 ❑ July 1 &Received By Julyf31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT AVE CHECKED <br /> AMOUNT <br /> FEE L,. . <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i 41A.NN4 L Y <br /> ` "OTHER <br /> 1 = <br /> Received by Dale 1 ti4d xnfReceipt No. Permit o Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O.Box 2009 STOCKTON,CA 952 <br />