Laserfiche WebLink
Applications Will Be Processed WhenSubmittedPropeny I..omple-Ga. o��� � •� - <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ale t arty business in the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness Name (DBA) 01 Address <br /> i Owner f Address <br /> d <br /> Firm Partners, Addresses and Telephone Numbers <br /> sBusiness Telephone Na ;F: Emergency Telephone No. <br /> Contractor Licence No. . <br /> L Applicants Name (Print) «�2� 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, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity GalWeights &Measures No. <br /> Equipment Parkin�`Address <br /> 2. E]'PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PFRCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT !?2 <br /> Job Address/Location p� •7 �~ <br /> �- � � <br /> IT; vAddress <br /> Owner _ �Cv <br /> 10 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY '❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equjpment Storage/Cleaning Locations) <br /> 6. 11 PACKAGE TREATMENT PLANT for July 1, -,June 30,.19 . . <br /> + Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No.Units Served <br /> r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,400 Sq. Ft., ❑ More Than 1,006 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homo owner crlir3nsedagent':: �ce*p"�-" � `Iz+'�� ! art` `� '^n;*�_,perform.=eoft�ework!cr%i ichth€spcrmilisissued,Ishallnotemployanyperson <br /> ir,auc11 manl,� as tc hecotne suh,ert tl t .: .} .�. s ��1 <br /> Contrmctcr's niri:Ea nr auh conrr�s►;�:;1,;::.,: .nom r rte�" ytivW�6. I certity that in the pertorr ce of the work for which this permit is issued,i shall <br /> employ persons�utrj,ct to warkmari's cotnpuzast;u�1 lad. �l Ca��,Ul, <br /> 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 olations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` <br /> 1� �r <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> aTHPR <br /> Received by Date Receipt No. Permit No. 1 suance to Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />