Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. a <br /> !; APPLICATION <br /> ��. (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> + ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ` <br /> Application is by adeto on busine 'n the jurisdictional area of theSisil,joaqo Loc Health Is ict / <br /> Business Name(DB ) C64 <br /> aOwner r Address Q a7. t""T•� �' <br /> Firm Partners, dresses and Telephone Numbers <br /> i Business Telephone NO. r <br /> - - - <br /> ,I a <br /> Emergency Telephone No. <br /> E <br /> Contractor Licence No. _�_ - <br /> _ T <br /> L Applicants Name(Print)—_- .� :Title ¢,�7 Date <br /> Please check Applicable Category (1-7)and ill In the Required Information <br /> I, <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 - -- -;- - Disposal Sites. <br /> Description(MakeNr.,Color) ll <br /> Serial No. -,CAL. License No. CAL. License Renewal No. <br /> Capacity Gat.;Weights&Measures No. <br /> .Equipment Parking Address <br /> 2. ❑ PUMPER YARD. II r I <br /> For July 1, June 30, 19' <br /> No.of Vehicles Stored 'h 1 <br /> _No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST j <br /> ' R.S.or R.C.E.Name _ R.S. or R.C.E. No. <br /> Test cation Test Date/Time <br /> 4�SANITATION PERMIT / I Q <br /> J Address/Lo anon �-� <br /> Owner. SAIe—,&I /l/O/� Address,. 4 <br /> -❑ SEPTIC TANK O CESSPOOL I: ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑"$EMPORARYI NEW ❑ REPAIR OTHER <br /> 5. 13 CHEMICAL TOILETS For July 1, June 30, 19 <br /> Jype CC�truction_ n w Disposal Site <br /> 1Nf0 of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location "w <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. I <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. r <br /> IRSKI)manoef aflxcteonbecomesubjeecitgnap.re eertlfiasfhe ry - <br /> to watman's Compensation1oRowlrla'�I cediry lAHlnClsperyrmaaaeo}trypyq }srahkk 0011a permltb Mausd.IMatlnelempi4yanyperaon <br /> Comreero:s hiring O sub-contei here ofCafil411tls:' <br /> —Ploy persons subject to workman's cornnpeaas,sf'lo�aws ghlorf�Na I Rs` A chitty that in the wormance of the work for which this perrtNr is issued,l shall <br /> h I hereby certify that'1 have prepare this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules regulatio oft San Joaquin Local Health District. - <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ` <br /> Fa!IS DW:d ANNUALLY ❑ PER.UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑July 1 l Rei Si Jury 31 <br /> .- REMIT . <br /> ' BASE EXPLANATION `"r BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> •' ( Y: DATE DATE REMITTED AMOUNT <br /> 1 <br /> FEE :77 It <br /> LESS e <br /> PRORATION - • <br /> PLUS I <br /> PENALTY '�. <br /> OTHER <br /> OTHER IY <br /> H en aT Data it Receipt No. Parm,!No. Isauanc0 OaN Marled Dellvtted APPLICANT RETURN ALL COPIES TO: -€NVIRONMENTAL HEALTH PERNrr/SERVICES 1001 E.HAZELTON AVE.,P.O.eex 3009 STOCKTON,CA SSaa1 <br /> I. <br />