Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> " APPLICATION <br /> (For Non-Transferabie, Revocable,•and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is by made to carry O usiness in the jurisdictional area ofthejSan Jpaquin Local Health District y, , <br /> W ff <br /> Business Name (DBA) P915 Address <br /> aOwner.- r ._._.... Address - <br /> J Firm Partners, Addresses and Telephnne Num ers + <br /> 0. Business Telephone No. Q -�- Emergency Telephone No. r <br /> Contractor Licence NO. - <br /> �Applicants Name (Print) - Title °.`.. Date <br /> Please check Applicable Category (1;4)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 &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD :y �.• ' <br /> For July 1, June 30. 19 tiV <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 4 + t <br /> R.S. or R.C.E. Name 1 _ R.S. or R.C.E. No. <br /> Test ocation Test Date/Time <br /> 4. FKSANITATION PERMIr� // <br /> Job Address/ ocatio ! Tu e A/F� I Liq P1 ► �✓F <br /> Owner EI AddressE <br /> ❑ SEPTIC TANK ❑ CESSPOOL KLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY F ❑ NEW *REPAIR 14OTHER <br /> 5. ❑ CHEMICAL TOILETS For July i,'June 30, 19 i RPENJOW <br /> Type Construction # *-Disposal Site •--- r., <br /> No. 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 <br /> Plant Capacity No. Units Served t "- <br /> 7. ❑ LAUNDRY For July 1,--June 30, 19 - . I - ` .f <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 lations of th n Joaqu' Local Health District. <br /> � <br /> APPLICANT'S SIGNATURE X lip <br /> Ar,_C� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑. PER SITE ❑ EACH - ❑ January 1 &Received By January 31r ❑ July 1 &,Received By JOy 31 <br /> K t.v BASE - EXPLANATION BDATE a REMITTANCE g REMIT <br /> T E REMITTED AMOUNT DUE CHECKED <br /> ' AMOUNT <br /> oil eO <br /> tr <br />' —FEE-.r...�.,.....� <br /> LESS , <br /> PRORATION <br /> PLUS > r_ 'A <br /> PENALTY <br /> OTHER <br /> OTHER _ -. .y _ _ } <br /> _ 3 -1 -0 <br /> Received by Date Receipt No: Permit No , I nce D Mailed DeSiveretl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �` <br />