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 /> A ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA) Z�©3_S --:kt-e-4 n►t1LQ r . and n tCttq Address <br /> z OwnerMF�c !J/ /Y 1 A e ? T Address -2o -/s <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. T S ._.... .....__.._...._.._..___. ._ ._......._.— Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Ppplicable 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 1 <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <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 /> Te s ocation Test bate/Time <br /> 4. SANITATION PERMIT �o QNE-2 L0004:(W4-,e 1b, <br /> Job Address/LocationD�- <br /> Owner 'n" &r/ 7 7W Address 6 E_ <br /> SEPTIC TANK ❑ CESSPOOL 1 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Jp NEW elrye-s ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r n <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(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. ,4.. <br /> ..- <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, - <br /> 1?twy»owrwrorlTaer►aedegsrrt's [� cant sthsl0itewigg_"lae VWinthepeetarmanteaftheworkforwhichtflispermitisissued,Ishallnotemployanyperson <br /> In such manner as to AecortrE slilrj tedF o wo�r#citsarfstotnpensatioR faros of f +fer :' <br /> CO>I1Wsctor's �4w s�8� t-rifts tAr iapOwlilM: "t certify that ift RIM ppiMan%,bf the work for mhEch this permit is issued,I shall. <br /> y 00 to WOainxartS 1:4m*'tis!llorl laws of ulfa*e, <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, and <br /> rules <br /> /and regulations of the San Joaquin Local Health District. <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �y AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS `j rl-ry <br /> PENALTY /! r (N <br /> i OTHER <br /> 4 <br /> OTHER <br /> Received by Date eceipt 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 /> 1 <br />