Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 4 <br /> f �w APPLICATION ,_ <br /> (For Non-Translerable, Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y <br /> Business Name (DBA) 13ournbC�h F Pin.z Address- <br /> a Owner <br /> (gull i �r�f�1_�t�.�s��`Tor ru PiativgAddress��rri� , <br /> Firm Partners, Addresses and Telephone Numbers c1�tTVI rr ,Uz Pdr -c�rnrtrT <br /> CL Business Telephone No. M6 6 19 -- Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) % W Title �►G► Date vis Aw <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, m June 30, 19 _ - --Disposal-Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No.' CAL. License Renewal No. <br /> Capacity Gal.,Weights& Measures No. . j <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored t <br /> No. of Chemical Toilets Stored r 1 <br /> 3. 0 PERCOLATION TEST , <br /> R.S. or R.C.E. Name TALr-?-v F1 qZZ4 <br /> E R.S. or R.C.E. No. <br /> Test Location 1&lr —-74 7119Test Date/Time <br /> 4. 1:1 SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address a A vI <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER � ��� yI <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -Ay 7 19 1 <br /> Type Construction --- Disposal SiteWilly i <br /> VAYUI TY <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ENVfRdIi ENTAL HEALTH DIVISION <br /> Operator Name Where Certified, <br /> Plant Location <br /> Plant Capacity No. Units Served ' <br /> i <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. 4. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, a2 { <br /> ules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X fL'r�fL �/Z lrB�Qi"L/2 T� <br /> a f i <br /> FOR DEPARTMENT USE ONLY <br /> aw <br /> Fee IS Due: 11 ANNUALLY ❑ PER UNIT 11 PER SITE.. E] EACH 1:1 January 1 &Received By January 31 ❑ July, &Rec a Bij y July 31 <br /> BILKING REMITTANCE $ <br /> REMIT /y <br /> BASE EXPLANATION AMOUNT DUE CHECKED d � r <br /> * DATE DATE REMITTED AMOUNT % 1 <br /> FEE Ev-03 50-CC <br /> i <br /> LESS y <br /> PRORATION - <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> Ind S- I`7� o .S- q� - <br /> Received by Date -.Receipt No. -- Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />