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 here y made to carry o u Hess in thtLurisdictional area of th an Joaquin Loca Health District.. r <br /> FBusiness Name [DBA) -_ -C411SA V-1 Zx '. _Address_, -O,J_2[ '7-Z '�� - - 1. <br /> z Owner Address .. - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No,- <br /> 1 Contractor Licence No. � <br /> Applicants Name (Print) Title���� A7rnj Date _ <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 - <br /> Description(Make/Yr., Color) <br /> Serial No. ► CAL. license No. CAL. License Renewal No. = <br /> Capacity Gal.,Weights 8r',Wasures 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 r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> .Test Loc �nTest Date/Time <br /> k.r 4 <br /> 4. SANITATION PERMIT 1' <br /> Job Address/ ocation 731 1 ) . <br /> Owner Address -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑'LEACHING FIELD ❑ SEEPAGE PIT 1 ❑-PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR OTHER��� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 y ' <br /> I <br /> Type Construction Disposal Site a°r: <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �"`�• I `y <br /> Operator Name r Where Certified sL <br /> Plant Location <br /> Plant Capacity �_ '"` No. Units Served <br /> 7. ❑ LAUNDRY ForJuly1; June 30, 19 <br /> SIZE: ❑ Less Than'1,000 Sq. Ft., ❑ More Than 1,000 Sq.'Ft. t t <br /> -❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I <br /> 4p , <br /> rpared this ppiication a d that twork will be done in accordance with Sany quip County <br /> ordinances, state law sandrl3 ataons oft an Jo uin Local Health District. <br /> +}. 4 <br /> r I ,JYr <br /> AP <br /> APPLICANT'S,SIGNATURE Fa <br /> f - ► FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH S ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> -. - DATE ,DATE - -REMITTED AMOUNT - <br /> kt i <br /> FEE <br /> LESS <br /> .r PRORATION <br /> 'PLUS. <br /> PENALTY <br /> - j OTHER <br /> <- OTHER. . <br /> Received by c Date Receipt No. Permit No. Iss ante uate- Mailed Delivered' <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O.Box 2009 STOCKTON,CA 95201 <br />