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 /> } LIQUID WASTE <br /> Application is erqby made to carry on business in the jurisdictional area of the San-Joaquin Local Health District <br /> ,F Business Name (DBA) 1 . FdLLGtL. Address <br /> -...b <br /> a Owner �.:,,�r/=ua�L+� , ._� Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.. - -Emergency Telephone No.r <br /> Contractor Licence No. 1'1�'�' <br /> L Applicants Name (Print, � �R Title Date <br /> Please check Applicable Category (1-7)and Fill.In.the Req.uired.1nformation r,; <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; June'30, 19 - - Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. * SAL-License No. CAL. License Renewal No. <br /> Capacity Gal Weights,& Measures No.- <br /> Equipment Parking Addrets"i-VI kC,= fir'— ---- ` �•...-- <br /> 2. ❑ PUMPER YARD .r <br /> For July 1, JUIN-0730719' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST . .. �j t <br /> R.S. or R.C.E. Name _ f _ S ti .,__ R.S. or R.C.E. No. f <br /> i : .. . ` , <br /> Test Location ( Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location f��1 _ % J/ - - 2�' Q %7 _ <br /> Owner t a I Address -- <br /> ❑ SEPTIC TANKA'� ❑)�CESSP.`6PL t ,�LEACHING FIELD ❑�y�/SEE GE PIT PACKAGE PLANT I <br /> ❑ PERMANENT #TEMPO`'�iARY. ❑' NEW iQ REPAIR ❑ OTHER = <br /> 4 <br /> 5. C] CHEMICAL TOILETS For July i;- Ju Pre . <br /> Type Construction ( Disposal Site <br /> No. of Units t # Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT or July 1 June 30, 19 1 <br /> Operator Name _ } Where Certified ) i <br /> Plant Location ( g ( ) <br /> Plant Capacity ( No. Units Served <br /> r, t <br /> 7. ❑ LAUNDRY For July 1, -June 30, 1.9 �.. ,s4q y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> '❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 re latio of the Sari Joaquin Local Health District . ' <br /> APPLICANT'S SIGNATURE <br /> --FOR DEPARTMENT USE ONLY 7 SSS <br /> Fee Is Due: ❑ A I UALLY ❑ PER 0NIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ J y 1 8 Receive 33y July 31 f <br /> __.... .. _ ._ _. REMIT -- <br /> BASE EXPLANATION BILLING REMITTANCE :1 AMOUNT DUE CI-{ECKED <br /> - - _ - DATE .- DATE }REMITTED C.�. AMOUNT <br /> FEE <br /> LESS <br /> "PRORATION F <br /> PLUS 57 <br /> ENAL`TY,�^^.�- _-----^�-..��.„ -^ —.:^�-.--W,.__-.�- --" -- �..wd. -, __dr�.. .- <br /> OTHER <br /> OTHER.... <br /> - 1 o <br /> Received.by Date- Receipt No. Permit No kssuancii Date Mailed Delivered <br /> ? ' <br /> APPLICANT—'RETURN ALL COPIES TO: yENY1FlONMENTAL HEALTH PERMITISERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 .k <br />