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 /> ENVIRONMENTAL HEALTH PERMIT <br /> �1. LIQUID WASTE'- <br /> ApplIcatI i hgr ,1 m e arty o si s }n the jurisdictional area of the 5 aqui oc I ajth Di5 yt. <br /> N Business {DBA) �- �' 'Address U y r� <br /> a Owner / C yf1 �� _ _ Address <br /> Firm Partners, Addresses an TelephoneCNumbers <br /> CL Business Telephone No. - Emergency Telephone IVo. "� 4 <br /> a - <br /> Contractor Licence Na. _ <br /> L Applicants Name (Print) E � ;- ;Title Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information .ts <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r _ <br /> For July 1, June 30, 19 .-.=-- - - Disposal..Sites. V , <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL, License Renewal No. } <br /> Capacity t Gal.,Weights & Measures No. I <br /> Equipment Parking Addr!aspcl <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,_19 <br /> No. of Vehicles Stored _ <br /> No...of'Chem ical,Toilets Stored <br /> C3",-0�PkdOLATION TEST ) -A. � <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 1 <br /> Testr`on�ca4ion'' ( ' 1 s t' Test Date/Time. ' <br /> 4. 'SANITATION PERMIT i67f <br /> Job Addre ssXocafion. 3J �� <br /> Owner" + } "` Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL C5EACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY, ❑ NEW 043EPAIR ❑ OTHER { <br /> 5. ❑1CHEMICAL TOILETS I For"Juiy'1, -June 30-19 P '+{ A <br /> I F,. - <br /> Type Construction Disposal Sit- <br /> No. of-Units - - -' - j-4— Equipment Storage/Cleaning Location"(s);•) l <br /> 6. ElPACKAGE TREATMENT PLANT ` For July 1 June 30 19 � � -� <br /> a. .°.r rJ�C;, t� ' 1'"'r'1, 1 t yK�?izr Where Certified ' <br /> yOperator Name - - , <br /> Plant Locaiion `> , " ) <br /> Plant Capa�city" ..r ~i- ; °�� No.'Units Served 1 <br /> 7.4O'.LAUNDRY For July 1, -June 30,-19 <br /> SIZE: ❑ Less Than 1,000 Sqf Ft., ❑ More Than 1,000 Sq. Ft. s <br /> C DRY CLEA ING, Chemicals Used/Amount/Mo. r <br /> oMaowneros cam.��­t-)nt•ssignaturecernfies,ehe"owing:"Icertifythatintheperfarmanceoftheworkforwhichthispermifisissued.lshallnotemployanyperson , <br /> in such manner I's to c ,:u subject to workmar►s compensation laws of CaliforniEL'. <br /> contractor's hirhig or stub-eontraciing siOMMM imr0f6atithe folbvieft: "I Certify that In the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's campensatian laws of Catitornia." 4 <br /> I hereby certify that I have prepared thistrap~ licaatio and'that fihe work wi I aq <br /> be done in accordance with San Jouin County <br /> ordinances, state laws, can gt�i o the San Joaquin�LocahHealth District. { <br /> APPLICANT'S SIGNATURE <br /> J 4 <br /> .._ .FOR DEPARTMENT USE ONLY. <br /> Fee 13 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El 'EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT I <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE - - DATE 'REMITTED -;.N . . AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> � <br /> OTHER <br /> OTHER _ - F - F <br /> t � �, � v <br /> Received by Date Receipt No. Permit No. I Issuan Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES` 1601 E.HAZEL'TON AVE.,P.O.Box 2009 STOCKTON,CA 95201- <br />