Laserfiche WebLink
C' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplicauon. y <br /> APPLICATION <br /> a- (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i hereby made o carry on bu 'Hess I/ the', tlonal area of the S-a J`o�aquin Local Health District <br /> yBusiness Na (DBA) x Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Num ers Emergency Telephone No. 1 <br /> a. Business Telephone No. 3 ' A <br /> a y � Q <br /> Contractor Licence No. Date <br /> s Title <br /> Applicants Name (P,rint)• <br /> Please checlk�Applicable Category (1-7) and Fill in the Required Inform tion <br /> 1. ❑ PUMPE0"VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July1-+• = June 30, 19 Disposal Sites <br /> Description(Mdke/Yr,_o16f) CAL License Renewal No. <br /> .,Serial No. m _ - CAL. License No. }s <br /> VV*11� t< Gat., Weights & Measures No. *+! <br /> Capacity <br /> Equipment Parking Address s <br /> 2. ❑ PUMPER YARD , <br /> For July 1, June 30, 19 ` <br /> No. of Vehicles Stored I ! <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST S <br /> R.S. or R.C.E.Name <br /> :..,If ,� R.S. or R.C.E.No. `6 <br /> E <br /> es'AINITATION <br /> Test Date/Time,Testion4. PERMIIT4/ r,� '' "'•�"—ez,& <br /> -AR Og <br /> Job Address/Loc Address -7�'�� ft; _jC. <br /> Owner <br /> 11 SEPTIC TA K 13 CESSPOOL L aACHING FIELD S PAGE PIS+^°'El 0A <br /> NEW REPAIR H RGE PLANT <br /> O <br /> I; <br /> 13 PERMANENT ❑ TEMPORARY <br /> 5. ❑ 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 ij-----June X-19 . I <br /> Where Certified i <br /> Operator Name <br /> Plant Location I <br /> Plant Capacity �� � No. Units Served <br /> 7. 13 LAUNDRY For July i, -June 30 19 Y <br /> ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft.❑ J <br /> SIZE: <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ation and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this appllc of the Sa uin.Local Health District. <br /> I ordinances, sta <br /> to laws and rules and ulatlons <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY j <br /> ik Fee Is Due., ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Ja uary 1 ceived By January 31 ❑ July 1 &Receiv REMITd By July 31 <br /> E BILLING REMITT $ AMOUNT DUE CHECKED <br /> hEff BASE EXPLANATION DATE ❑ REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 23 �O <br /> ' Receipt No. unit No. Issuance Date Mailed Delivered <br /> Received-by Date _ —i° <br /> 1601 HAZELTON AYE.,-P.O.Box 2699. STOCKTON,CA 95201 <br /> f. - APPLICANT—RETURN ALL COPIES 70: � ENVIRONMENTAL HEALTH PERMIT/SERVICE ���� �� F _`._;. <br />