Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
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 /> rENVIRONMENTAL HEALTH PERMIT <br /> 0 LIQUID WASTE . <br /> (moi Appl icat' is hereby #tocarryonbu iness t e.juri ictional area of the n Joaqui Local HealthDistrict�Busnes ame (DBA}aOwner Address L) Firm Partners, Addresses and Telephrs <br /> CL Business Telephone•No. Emergency Telephone No. r <br /> Contractor Licence NO. y- ;t 7-_7- <br /> T s <br /> b <br /> Applicants Name,'(Print} .Y , <br /> Title. Date-_,.h <br /> fl -.� .c, a ' <br /> Please check Applicable. d egory.(i 7).and Fill the Required Information w r,j I{Y3e <br /> i. ❑ PUMPER VEHICLtE,PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For.July.1-�� 'r' �Jun�•30, ig.: : �__ :. _ rDisposal Sites <br /> Description`(Mahe/Yr Color),- <br /> r CAL. License Renewal No. ' <br /> Serial No. CAL. License No. <br /> r Capad ity.+ � T' `a Gal:,Weights& Measures No_ � <br /> t Equiohien%Parking Address <br /> 2. ❑ PUMPER YARD e <br /> For July i,_ *--_dune 30, 19 <br /> NO.of Vehicles Stored r� k <br /> No. of Chemical Toilets Stored t <br /> ->3—❑,PERCOLATION.-TEST- - -- <br /> R.S. or R.C.E. Name + _ R:S. or R.C.E: No. <br /> Test Lo/cation Test Date/Time <br /> 4. L��SANITATION PERMI E' <br /> Job Addr /Location E ` <br /> Owne ;Address <br /> ❑ SEPTIC TA ❑ CESSPOOL :�` "❑ EEACHfNG FIELD -:C EEPAGaE...PIT�.-.❑-PACKAGE-PLA. T- <br /> M PERMANENT ❑ TEMPORARY ❑ NEW ' Q REPAIR ❑ OTHER - - V <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 J <br /> -Type Construction-r: " M%posal-Site <br /> No. of Units '' � " Equipment Storage%Clea ing-gcatiorV(t(} <br /> � . <br /> B. 13PACKAG.E TREATMENT PLANT For July 1.,.-June 30, 19 s - <br /> .�`=` t Where Certified <br /> Operator Name - . <br /> Plant Location <br /> Plant Capacity r = - No.Units Served <br /> 1. ©LAUNDRY For July 1, -June 30-1ig. <br /> SIZE: ❑ .Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. F <br /> j <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owrwrorKcensrdnsent'ssif,:.ty c_ t=fir?-k -�F¢ itoerr{ `I t-NOintheperfermanceoftheworkforwhichthispermit-is issued,Ishallnotemploy any persc7 <br /> in such man-.-.r Ds lo bewi! olbj Lt!n <br /> Contractor's hirivo G .:�.:.^. - .,.�^� -.I--- t ,[:.ai lF iaik :uFny: ] CETtity that in teSE pCffO.fm rlCC of the'r4)rl(for t:°f!iCh this Rf;rli#i5 ISSkJB�t,l 5 811 <br /> employ persons Sub;t t#V rdcli!i a,t' i?lpc!r ai cii;«Ksoi f airSi7 i1Fa <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, nd rules an regulations of the San Joaquin Local Health District. i <br /> ` APPLICANT'S SIGNATURE X <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 /> REMIT <br /> BASE EXPLANATION BILLING > REMITTANCE $ AMOUNT DUE CHECKED <br /> .. DATE ,DATE REMITTED ; AMOUNT <br /> FEE <br /> LESS <br /> PRORATION T y <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> + <br /> ' OTHER <br /> OTHER _ s <br /> Date _ Receipt No - Permit No. issuance Date Mailed Delivered <br /> Received by - <br /> APPLICANT=RETURN ALL COPIES TO:- ENVIRONMENTAL-HEALTH-PERMITISERVICES a 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> � I�.l�eG� <br />