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 /> Application is e h y made to carryon basin ss In the' dictional area of the San Joaquin Local Health District ; <br /> Or uris <br /> Business Name (DBA)� � `C� azC, Address <br /> a Owner_ �5 Yt1 P 7��C h L, Address_. <J_� _ <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 77 -1Emergency Telephone No. L <br /> Contractor Licence No. <br /> LApplicants NTitle �C c5nA,4-1,&�64 s C Date 12 ,- <br /> Please <br /> 2 ,-Please check Applicable Category (1-7)and Fill In the Required Information ` <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �1 <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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Tes ocation Test Date/Time <br /> 4. �SANITATION PERMIT _ <br /> Job Address/Location <br /> cn Owner �r�--a �, z 1U�) =_ Address + <br /> El SEPTIC TANK ❑ CESSPOOL IR LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT <br /> E] 111:1 <br /> PERMANENT TEMPORARY NEW CC-REPAIR 91-OTHER ✓ 0 1 1C `"Z-- v 1"'14 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site E <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified n ' <br /> Plant Location <br /> s , <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,` ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have preparV this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules d r ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X } <br /> a <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 /> BILLING REMITTANCE $ <br /> - BASE - EXPLANATION DATE DATE REMITTED AMOUNT DUEREMIT <br /> , CHECKED _ <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No- Permit No. Issu ce Datd Mailed NINered r <br /> APPLICANT-RET_URN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2Do9 STOCKTON,CA 95291 I <br />