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 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) S LJ, Address r S7vC <br /> i Owner Address <br /> FirM Partners, Addresses and Telephone Numbers' �� „M - <br /> aBusiness Telephone No. �S- g.7 Emergency Telephone No. <br /> Contractor Licence No. - /5.3-S-g-3 <br /> Applicants Name (Print) -i- A Title ��cJ^�C-2 Date —2�-�/. <br /> Please check Applicable Category (1-7)and Fill in the Required Information y ,, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 7 <br /> For July 1, June 30, 19 Disposal-Sites - <br /> Description(Make/Yr., Color) + _ <br /> Serial No. T 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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E..No. ' <br /> Test Location Test Date/Time <br /> 4. XSANITATION PERMIT <br /> Job Address/Location V16 Fz-aojaz S'T <br /> Owner F9 AAlh:� I/A-7-7'A Address 's <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD IX SEEPAGE PIT" ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ;A 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) <br /> 6. Cl PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified' <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,; 11 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. �K <br /> 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 regulation the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - -- <br /> FOR DEPARTMENT USE ONLY <br /> _ Fee Is Due: ❑,ANNUALLY ❑ PER UNIT ❑ PER SITE s❑ EACH. ❑ January i &Received By January 31 ❑ July f &Received By July 31 <br /> e e . <br /> REMIT <br /> F ✓ r BILLING , REMITTANCE $ <br /> y BASE EXPLANATION AMOUNT DUE CHECKED <br /> F DATE DATE REMITTED AMOUNT <br /> O <br /> -FEE <br /> LESS �f_;' <br /> PRORATION)' - - - <br /> PLUS <br /> i, PENALTY <br /> OTHER <br /> 1 444 . <br /> OTHER . <br /> L11 Z <br /> Received'by Date .Receipt No. Permit No. /Issuarke Dae C Ma ed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boll 2009 STOCKTON,CA 95201 <br />