Laserfiche WebLink
d Properly <br /> te <br /> Applications Will Be Proc`e`ssed When SubbmiitPL`CATIONp e e e <br /> (For Non-Transferable,Revocable,and Suspendable) f SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ��,� '- _ <br /> LIQUID WASTE <br /> Application is hereby/made to carry on business in the jurisdictional area of the SanJoaquin Loca ea Istri ct <br /> 71n4z Address <br /> mBusiness Name (DBA)_ Address <br /> 3.1.+• <br /> Z Owner. - <br /> 4 . <br /> J Firm'Partners, Addresses and Telephone Numbers Emergency Telephone No.v <br /> aBusiness Telephone No <br /> Contractor Licence No. 4 " " '`w q. Date. 7- Z_ <br /> Title' } <br /> Applicants Name (Print) I.,... . <br /> uired Information <br /> Please check Applicable Category (1-7)and Fill In the Req <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r� <br /> For July 1, -June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> " CAL. License No. <br /> Serial No. 3 <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> , . <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> + <br /> 4. X SANITATION PERMIT "" � 5� <br /> Job Address/Location Z �' <br /> Owner +� Address <br /> PAGE PIT ❑ PACKAGE PLANT <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD SEEREPAIR OTHER A1V'ADdA1 o� -V <br /> 7 <br /> NEW <br /> PERMANENT ❑ TEMPORARY O <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19— <br /> Type <br /> 0, 19Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B" ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified i <br /> Operator Name <br /> Plant Location t <br /> ( No. Units Served <br /> Plant Capacity <br /> 7. Cl LAUNDRY For July 1, -'June 30,°19 <br /> SIZE: ❑ Less Than 1,000 Sq Ft., C3 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemlcals Used/Amount/Mo. y �� <br /> Hiameownerorlicensadagent'ssignature oerifl-tltefatlawing:"Icertily that'in the performance of the work for which this permltisissued,Ishall notemplo an rson <br /> -in such manner as to became subject fo worknam's cornpen-aalion laws of Calif-mia_' <br /> Contractor's Airirtq or sub-contracting sionatura certifie4 *he fo lowing: "I certify that in the performance of the work for which this permit is issued,i shalt <br /> employ persons sublect to workman's compensation laws of Caliiornla," <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 andr ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> w_ - h <br /> ' FOR DEPARNT USE ONLY <br /> ❑ ❑ PER UNIT' El PER SITE ❑ EA H _❑ January 1 &Received By January 31 ❑ July 1 &Receivend EMIT By July 31 <br /> Fee IS Due: ANNUALLY <br /> > BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE. DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION y <br /> PLUS i <br /> - PENALTY <br /> r OTHER •��` <br /> OTHER 4 + <br /> v <br /> ReceivedYby Date Receipt No- <br /> ~ Permit No. suance.Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br /> APPLICANT-RETURN ALL COPIES TO: ,ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />