Laserfiche WebLink
r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - , APPLICATION <br /> Y.•- (For Non-Transferable, Revocable;'and Suspendable) SEPTAGE <br /> 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 /> rn Business Name (DBA) Mr.T) l SeptSeptz r. &�cP. <br /> kh n ' Address W - _ <br /> zOwner T. R- Address Same <br /> Firm Partners, Addresses and Telephone Numbers <br /> n a Business Telephone No.. � �—Q/� 7 T_ Emergency Telephone No.9 j�l �7 - <br /> z 1y , K Q ] <br /> 1 Contractor Licence No._1.3 7, <br /> LApplicants Name (Print) Title n .rear Date <br /> Please check check Applicable Category (1-7)-and Fill in the Required Information v ,� C. ,;.•,.. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s <br /> For July 1, June 30, 19 "- Disposal:Sites - <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 e, ' <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored r- <br /> 3. ❑ PERCOLATION TEST r } <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time ` <br /> 4. ❑ SANITATION PERMIT '" <br /> Joti Address/Location 410 # <br /> Owner Addrescz ' <br /> ❑ SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT 0 PACKAGE PLANT ' <br /> ❑ PERMANENT ❑ TEMPORAR ❑ NEW REPAIR ❑ OTHER <br /> 1, _ - <br /> s. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> - Type Construction Disposal Site e r <br /> No. of Units-equipment Storage/Cleaning Location(s), I <br /> 6 ❑ PACKAGE TREATMENT PLANT .For July 1, -June 30, 19 w _71 <br /> f Operator Name `•`+ Where.Certified <br /> Plant Location � > <br /> _ �: <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. f { <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> I' hereby certify that i have prepared'thi pplication and that the work-will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rulesnd r g I tions of the Sa Joaquin Local Health District. <br /> 'APPLICANT'S SIGNATURE X <br /> 15a 7r <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 /> I REMIT <br /> BILLING I REMITTANCE $ <br /> BASE EXPLANATION !.- DATE 'DATE REMITTED AMOUNT pUE CHECKED <br /> "1 AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> •' PENALTY <br /> OTHER O <br /> OTHER - __ .+—_ _ E _ <br /> r S_74. <br /> r. Re eivey Oate -, —?Receipt No. - ,Permit No. Issu nce Da a Mailed Delivered <br /> k <br /> t APPLICANT=RETURN ALL COPIES TO: I ENVIRONMENTALHEALTHPERMIT/SERVICES `1601 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,CA 95201 <br />