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} quin Local Health District <br /> Address 9L �� l�[ <br /> Business Name (DBA) f <br /> i Owner A 2 <i�77 _ Address - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ` <br /> Applicants Name (Print) Titled Date 1 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4 <br /> M <br /> r <br /> For July 1, June 30, 19 Disposal Sites i <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 3019 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ;• '_ `"` a <br /> R.S. or R.C.E. Name '4.` R.S. Or R.C.E'No. t y <br /> Test Location 7 Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Own ~, 11-2,v t 6 Address CF, o 7c-A <br /> l�SEP-r1C`TANK—❑'CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑.REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site �-- ' , <br /> No. of Units Equipment Storage/Cleaning Locatiori(s_)�. t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 'L-- here-Certif led f <br /> Plant Location _ } <br /> Plant Capacity �No. Unit's-SL&r_4l 'a +� 4 <br /> ❑ LAUNDRY ForijUly 1, -June 30, 19,/ <br /> 'SIZE: ' ❑ Less Than 1.,000 Sq. Ft., ❑ More=Than 1,000 Sq' Ft.t <br /> ❑ DRY-CLEANING, Chemicals Used/Amount/Mo '^ 0fi y r <br /> I hereby certify tht I have prepared-:this application and that the work will be done in accordance with�an``oaquin'County <br /> ;ordinances, state_-laws, and rules and reg -tiohs. f 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 ❑EACA,. ❑ January,l-&Received By January 31___ July`7'&Received By J Ey 31 <br /> BASE EXPLANATION REMIT <br /> BILLING REMITTANCE 4� , $ AMOUNTDUE CHECKED <br /> DATE '+^- DATE "REMITTED AMOUNT--- <br /> FEE a: � 5; - <br /> _LESS # <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> -.—..OTHER— <br /> OTHER <br /> ,.,.,"'OTHER—OTHER -wl' -} <br /> Received by Date ,} Receipt No. -Permit No.. A ssuan a Date Mailed .,Delivered <br /> APPLICANT—RETURN ALL COPIES TO`. ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601E HAZELTON AVE.,P.O:Box'Wi)9 STOCKTON,CA 95201 <br />