Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable and Suspendabte) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Applica Ion Is hereby made to carry an busi ess'n the juri dictional area of th San Joaquin Lo al Health istrict <br /> W �d <br /> yBusiness Name {DBA) Address <br /> z OwnerAddress � <br /> JFirm Partners, Addresses and Telephone Number �• <br /> mer <br /> encBusiness.Telephone.No >4 _. " -�•, <. 9_. . y aP,F a Na <br /> a enc Tele hon <br /> a , <br /> Contractor Licence No. - <br /> Appfic2nts Nam -e (PrinE) _ ' Title Date_ <br /> an _. .t <br /> Please check Applicable Category (117-)-and'Flll.ln the Required Information .y. <br /> 1j ❑�PUMPER,VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For.July 1,:- `+ :,June_30;19 =,Disposal Sites, = - <br /> Description(Make/Yr.,Color) -F <br /> .Serial No. CAL. License No. ! CAL. License Renewal No. <br /> -Capacity' --- -Gal •Weights &-Measure <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD` l <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3.' ❑ PERCOLATION TEST <br /> 1 ( R.S. or R.G.E:No; ? + <br /> R.S.for R.C.E. Name _ �,, <br /> Test Location ( eSt�Date'/dime j <br /> 4. i❑ SANITATION P 1 <br /> Job Addr s/Location • - ' <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPbOL EA'CHING F1EL-D-, IICSEEPAGE PIT- ❑ .PACKAGE PLANT <br /> s <br /> ❑ PERMANENT ❑ TEMPORARY �►-? NEW #� + REPAIR w OTHER <br /> 5. ❑ CHEMICAL TOILETS For JulyA., -June 30, 19,:. <br /> Type Construction - Dis al(Site_NO.' Units f 1. Equipment Stgrage/Cleaning Location(s) <br /> 6. PACKAGE TREATMENT}PLANT For July 1, -June 30, 19 �^ s <br /> t # <br /> 1.1{•f fly;4 "fes` r Where Certified <br /> Operator Name <br /> 'Plant Location ' j 4 <br /> Plant Capacity a ) 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 /> I hereby cer I y 'have prepared tt' application a that the work will Lie done in accordance with San Joaquin County <br /> ordinances, state laws, rule an rtgl atio of he n Joa in L cal Health Distrix. r' <br /> APPLICANT'S SIGNATUR <br /> t 3 <br /> � I 9 <br /> FOR DEPARTMENT USE ONLY <br /> �- 4 Janua. la&Received By January 31 ❑ July 1 &Received By July 31 <br /> I Fee Is Due: ❑ ANNUALLY'. ❑ PER UNITS .-Jl PER SITE�.. ❑ EACH z,'}J--�t 4Y' - <br /> j - REMIT <br /> BILLING REMITTANCE - {. �, $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION pATE"'3.-'a" `` D'j E- � °�- IREWTTEC AMOUNT <br /> t <br /> FEE <br /> LESS [ } - <br /> PRORATION <br /> PLUS �- <br /> - PENALTY - - - y/3• <br /> OTHER '+'Cf f ".S `•' } <br /> OTHER <br /> - .. r <br /> 5 ,. F <br /> t s. Issuance Date Mailed Delivered <br /> i Received by ate Receipt-No`; g t Permit-No � ,._v,,.3- i ; <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERINIT/SERVICES'-"''•' 101-' <br />