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 /> M p ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic tiorLj§ reby d r b sin in the j i fictional area of th�++�n in�octal�ealt �strlct <br /> UBusines Name (DBA) t ddress z IJV -- <br /> QOwner Address <br /> nu Firm Partners, Addresses an a-liantione.Numbers <br /> 5. Business Telephone No. Z Emergency Telephone No. <br /> 46 <br /> Contractor Licence No. <br /> L Applicants Name (Print) _ Title ate t <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. GAL.,License Renewal No. i <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 /> ❑ SANITATION Pm n F <br /> J <br /> ob Ad s/Lo 'on. o � �---- <br /> Owner ;rAdd r , <br /> ❑ SEPTIC TANK ❑ CE SPOOL ACHING MEL[) 1= pPA -kT ❑`PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW EPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units <br /> �._ Equipment-Storage/Cleaning Location(s) ) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name - WhereCertified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 �s <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. - <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Home ownerbrlicensedegenYssignsturecertifrRsthefoilowu+g:`lcenlfthat in heperformance ofthe work for which this permit isissued.lshall notemployanypercon <br /> in such manner as to become subject to workman's compensation laws of California,' <br /> Contractor's hirirr4 or sub-contrftoft signawle certMes the following: "1 certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject townmman'scompensationlaws ofCalito ia-" <br /> I hereby I have pre ed his a 'catio d that the will be done in accordance with San Joaquin County <br /> ordinanc a la a les n an Joaquin al Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT + <br /> BILLING REMITTANC $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> y DATE DATE REMITTED AMOUNT <br /> FEE .!r? S `� <br /> LESS <br /> PRORATION <br /> PLUS 2 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ate 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 />