Laserfiche WebLink
Applications Will Be Processed When Submitted Pr'sperly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 0 (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE i <br /> ENVIRONMENTA HEALTH"PERMIT <br /> LIQUID'1 WASTE <br /> Application is her mad®to arty On siness In iunsdictionai area of th n J yin Local He Ith Di tri t /a,, <br /> Business Name (DBA) i� L Address. � T J �y�' <br /> aOwner Address �. .. <br /> J Firm Partners, Addresses and Telepho �Nu�mbb rs <br /> a Business Telephone No. 02 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) �� Q iF ,Title Date- w y <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 = F <br /> Description(Make/Yr., Color) I l <br /> Serial No. CAL. License No. CAL. License'Renewal No. ,. <br /> Capacity Gal.,Weights& Measures No. i <br /> I� <br /> Equipment Parking Address a <br /> 2. ❑ PUMPER YARD -N <br /> For July 1, June 30, 19 <br /> No. of Vehicies Stored ` <br /> No. of Chemical Toilets Stored I ; <br /> 3. ❑ PERCOLATION TEST <br /> v <br /> R.S. or R.C.E. Name ' R.S. or R.C.E. No. <br /> Test cation t Testi Date/Time <br /> 4. P&SANITATION PERMIT <br /> Job Address/Lo ation <br /> i'Owner f ddress II <br /> ❑ SEPTIC TANIf 11CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW gREPAIR ❑ OTHER <br /> jI <br /> 5. ❑ CHEMICAL TOILETS For'July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No.-of Units t '� Equipment Storage/Cleaning.LocIation(s) <br /> 6 ❑ PACKAGE TREATMENT.PL ANT For July 1,-June 34, 19 6: <br /> Operator Name r i-. {� Where Certified <br /> Plant Location �. <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: El Less Than 1,000 Sq.'FCT ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/AmounVMo. = <br /> Home olxnarorlicanstsddgestt'e_ai rs�aurecer�at€sst#,�f:sl6ot�;n3;"Ircf;fyith.0i:!theparformanceofthe work for vihi&thisp,fmitisiss er,E�",a.#r�:a' ;:I^;ony r• <br /> in such manner as to become sltl ^ct to 4 0 r pen �tI 4'. 4 le 1rr 11 <br /> CorLtractor's hiring that ill tl'£rCrt6C,,.3P;C Li,y1 �`.'Cf iQr tkhiC" 21'7i". iSS�D7.,i S, !I <br /> employ <br /> 3 't <br /> kM � <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 rules and r gulation the Sari Joaquin Local Health District. <br /> ' � - it 1 i <br /> APPLICANT'S SIGNATURE X <br /> a II <br /> .. t. 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 I REMITT NCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DAT t REMITTED <br /> AMOUNT <br />! FEE <br /> PRORATION_ <br /> PENALTY �' -� '" 'li X . <br /> OTHER - - <br /> OTHER !�. <br />! Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered . <br /> APPLICANT-RETURN ALL COPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - '' -1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br /> L <br />