Laserfiche WebLink
'Tr•"--'........ ..... ...� _ .....-.--.. ....-.. __,._.._•_�__ 'ter-'-r —____�__.__. __ -.... _ _..,.- -... ..,.,..._. .._. . <br /> APPLICATION <br /> +� Ir Non-Transterable,Revocable,and Suspendab SEPTA�OE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is her by de carry; sine the jurisdictional area of the San JoaQUin Lo I Healt District <br /> rness Na BA) Add ess <br /> z _ Address l _ <br /> z er <br /> f irm Partners, Addresses and Telepho Numbers __7q_1—, <br /> �// <br /> iLBusiness Telephone No. ��_. � � Emergency Telephone No. y <br /> Contractor Licence No. 3. O� <br /> LApplicants Name (Print) ti`s Title / �� �- Date ' ` <br /> Please check Applicable Category (1-7)and Fill In the Required information. 4 <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 Na. CAL. License Renewal No. <br /> Capacity Gal,Weights& Measures 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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test�,.toation Test Date/Time <br /> 4. ed SANITATION PERMIT <br /> I Job Address/Loc on � 3.3 7 <br /> OwnerAddress <br /> ESEPTIC TANK CESSPOOL LEACHING FIELD 8-iEEPAGE PIT ❑ PACKAGE K ANT W <br /> UERMANENT 13 TEMPORARY M-IgEW ❑ REPAIR ❑ OTHER W <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> e Construction Disposal Site <br /> I..,: of Units Equipment Storage/Cieaning 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 <br /> 7- ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft_, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. !I <br /> Horne owner or licensed agent's signature pertifiea tele foilnvAng:"I certify`l a'f^the as rtormarcp of the work Tor which this permit is isslred.l Shrill not employ any person <br /> in such manner ins G::become sclhject to.wDrkinar,'s com9ensation lavas nl Ca i10, <br /> Contractor's hiring or sub-contracting 5i9rrawm cettifies:t`1e-doltoGYinu. I certify that in the performarlcp of the work far which this permit is issued,t shall <br /> employ persons si;;iect to workman's ecmpeasaticr�laws of <br /> t uaiifor<<-,ia:' <br /> I hereby certify that I have prepared'this ;ca};i. and that the works will be done in"accordance with San Joaquin County <br /> ordinances,state la a rul Inh'O San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due- © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A 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 /> 14,5 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> s <br /> OTHER <br /> Received by Date Receipt No Plarmit No. rA ssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16111 E.HAZELTON AVE.,P.O.Box 20091 STOCKTON,CA 95201 <br />