Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> N (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application/�iis,�hereby pmade�t�o�ca�o business in the jurisdictional area of San Looaquin Local Health District <br /> F Business Name (DBA)VA r��P�S i.� � � t �� AddressTp <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _9 07 Emergency Telephone No. <br /> Contractor Licence No. <br /> EZ <br /> Applicants Name (Print) TitleAC- Date — �- <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. r `` ; C*. License Renewal No. Cott <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. SANITATION PERM% �, � ���� <br /> Job Addre_ss`L�ocation , <br /> Owner t( Address .4"77 -��� Z� STI•Z <br /> ❑ SEPTIC TANK ❑ CESSPOOL SI=LEACHING FIELD ALSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW WREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �+1 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning...Locaton(s) <br /> 6. ❑ 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., ❑ More Than 1,000 Sq.-Ft <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Howmawne•erficensedagent•ssignatn+re1 certify thet in the performance df thewort(forwhich this permit is issued,I shall not er, I y nyF <br /> in such manner at to tyecome subject to workrnar s compensation lar.-s of Cdtifontic.' <br /> Conuastor's biting or sub-contracting signature cerUtiec._.ej4Dllbwing: -I Cliftify thzt in the rta <br /> perforncu of the work tar which this permit is issu.: aha:' <br /> employ persons,Subject to workman's com)teosatle iawsltf C19litr ;} <br /> I hereby certify that I,,have repared this applicatioif and that the rk willbe done in accordance with San Joaquin County <br /> ordinaAces, state laws, I snand reg Ions of tNa n J In ogal alth District. <br /> APPLICANT'S SIGNATURE X1904� <br /> O <br /> ROR,DEPARTMENT USE ONLY <br /> Fee Is Duj; ❑ ANNUALLY r ❑ PER UNIT ❑ PER SITE P.EACH ❑ January 1 &Received By January.31 ❑ July 1 &Received By July 31 <br /> 1 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASP, EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> S"— <br /> FEE <br /> LESS til <br /> PRORATION <br /> PLUS , <br /> PENALTY' � <br /> i <br /> OTHER <br /> OTHER a ( <br /> '7 <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN A�L COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />