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 /> r <br /> Application is hereby made to carry on business in the jurisdictional area oft San Joaquin Local Health e�District <br /> OF Business Name (DBA) +-d, e21 !P�� NS..+ Address r0,&x14SZD ., <br /> i Owner Address - <br /> J Firm Partners, Addresses aTelephone Numbers <br /> aBusiness Telephone No. .uy'-S607 Emergency Telephone No. <br /> Contractor Licence No. ' <br /> Applicants Name (Print, � � v Title 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,-19t =j _ Disposal Sites. <br /> Description(Make/Yr., Color) <br /> Serial No. -' CAL. Li ense No. CAL. License Renewal No. <br /> Capacity ` Gal., Weights &Measu es-No. <br /> Equipment Parking Address -- <br /> 2. ❑ PUMPER YARD <br /> For July 1,_ 4 30, 19 } <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. El PERCOLATION TEST �` �'` t ' <br /> R.S. or R.C.E. Name R.S.;pr R.C.-F—No. <br /> Test L cation. Test Date/Timis — <br /> 4. SANITATION PERyiT <br /> Job Address/Location <br /> Owner Addr s Cl <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD EEPAGE PITT ❑ PACKAGE PLANT <br /> PERMANENT-.d ;❑�TEMPORA'RY �1`11 NE1/V i/ ' ' REPAIR` ❑ OTHER t <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No:of Units --- Y --m- 4ipmeht Storage/Cleaning-Location(5)-°­L <br /> 6. 4❑ PACKAGE TREATMENT PLANT For July.1, -June 30, 19 t <br /> Operator Name r »- Where Certified <br /> ,,Plant Location <br /> y < <br /> Plant Capacity No. Uniis Served' <br /> f7. ❑ LAUNDRY For July 1, -June 30, 19 i t <br /> f <br /> iSIZE: ❑ l2ess Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 5 <br /> © DRY CLEAiNING, Chemicals Used/Amount/Mo. r )` <br /> - Home Owner orNeensedwfront'sHcriatarec2rViriazthufoilovv-i.nm1ertifyth,.,.19the dornrim,3 csof <br /> i in such manner as to became Subject to ?iiar�ork;or.�':Icht7isPermit isissueJ,lstal; niempioyanyperson <br /> wrcrkma^s [ <br /> ceznpensa?iorl ,tk a cf C%+iifbrn? # <br /> I Contractor's wring Or Sub-cCnt;a,;ti:2 signaturF: Certifies thc4 following: "'I CEliii]+ill$;in the parigrmance of tie%ork for%vhich this permit is1ssued,i Shall <br /> emp€oy persons subject to workman's compensalior!lavas of California." i. <br /> i I hereby certify that Ihave repared this application and that the work will be done in accordance with San Joacjuin County <br /> ordinances, state lawssand regula ' sof the oaqui oca H District. L; <br /> APPLICANT'S SIGNATURE X <br /> 1 t FOR DEPARTMENT USE ONLY <br /> i I Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J3nuary 1 &Received By January 31 ❑ July 1 &Received By J 1 <br /> REMIT <br /> i r 'BASE - EXPLANATION BILLING REMITTANCE $ '-- AMOUNT DUE 4 CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> s "r <br /> FEE <br /> tija`' <br /> t �, r 4 •" ' <br /> t 6 <br /> LESSt <br /> ► PRORATION <br /> x — � <br /> PLUSAP f <br /> PENALTY - <br /> ! OTHER <br /> .OTHER ., :. . .. <br /> Received by Date - Receipt No. Permit No. - Issua ce Da Mailed - Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES- 1601 E.HAZELTON AV .,P.O.Box 2009 STOCKTON,CA 95201 <br /> y — E <br />