Laserfiche WebLink
I Appllcattons Will Be_. rcessed When Submitted Properly Completed.Be 5._ 'To Sign The Application. <br /> C APPLICATION <br /> (For Non-Transferable R6ocabii;�ind Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> LIOUIO WASTE _ <br /> Application is h by made to carry business in-the jurisdictional area.of t San oaquin.iLoSpI Health District ,- <br /> i <br /> Fl3usinessName(D6AJ �•/sr�T 4,�/��,�f1G1-`' Address�Q,�Q� ��, <br /> _ - ° -f <br /> Owner Address <br /> i Firm Partners,Addresses and TeIe n Num e s �^ <br /> I 6 Business Telephone No.: ` = Q - . .Emergency Telephone No. _ <br /> 1 Contractor Licence No. VS12 <br /> �ApplicantsName (Print) '° s Title,. rST Data,- <br /> Please check Applicable Category•(11-7)and Fill in the Required Information,,. c J{. �►� .�4�.r.' .•����.:, s ,• ^;-,. r� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) �• �� <br /> For duty 1,• - June-30, 19 _= Disposal Sites- <br /> Description(MakeNr.,Color) <br /> Serial No: _CAL.License No. ' CAL.License Renewal No. <br /> Capacity' _ Gal.,Weights 8 Measures No. <br /> Equipment Parking Address „' �- <br /> 2. ❑ PUMPER YARD 'For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> i R.S.or R.C.E..Name R.S.or R.C.E.No. V <br /> Test cation Test Date/Time <br /> 4. <br /> Test <br /> PERMITY ' .. <br /> Job Addre Location f 1 <br /> t Owner ,y Address <br /> WSEPTIC TANK ❑ CESSPOOL Ja LEACHING FIELD 'pr SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY )d NEW d REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �C <br /> Type Construction ' R�� Disposal Site C <br /> No.of UnitsI�-- Equipment Storage/Cleaning Location(s) t <br /> 6. ❑ PACKAGE TREATMENT.PLANT' For July 1,-June 30, 19 <br /> Operator Name Where Certified: <br /> Plant Location I� � "V <br /> --s-+w <br /> Plant Capacity No, Unita Served <br /> 7. ❑ LAUNDRY For July 1,='June 30, 19' <br /> k SIZE: ❑ Less Than 1,000 P. q. <br /> Sq. Ft, ❑ Mare Than 1,000 Sq.*Ft. , r <br /> {] DRY CLEANING,Chemicals Used/Amount/Mo- <br /> % } <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 ru s and re tions of a an Joa• uin•Local Health District. <br /> APPLICANT'S SIGNATURE X 4.— <br /> FOR <br /> DEPARTMENT-USE bNLY , <br /> Fee is Due:❑ ANNUALLY. ❑ PER UNIT _ ❑ PER SITE I ❑ EACH- ❑ January 1 S Received By January at - ❑July 1 8 Received By July 31 <br /> • - BILLING I RbITTANCE ; REMIT <br /> _ :BASE EXPLANATION AMOUNT DUE CHECKED <br /> t- - " s ,4;-• - -i:-s:.�;;.DATE,�„ DATE - 'REMITTED' 711L10UNT - l <br /> S 1 <br /> � FEE <br /> PRORATIONAIV- -^•v .• w -- } {1'"r .t <br /> PLUS '•.,. _ _ _ '+1 .,Y l - <br /> PENALTY �.wr . ..,b ,. _ .A—, .a.a tit- al 40. <br /> 9 �' <br /> OTHER <br /> ,h <br /> OTHER .u,- I .. r. kip••• . <br /> Received by Date Receipt No. permit NO - Issuarilte Dati Mailed Delivered. <br /> b • APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERfAIT15ERy"CES 1601 E.HA-ELTON A ,9os 2'009 STOCKTON,CA 96201 - <br />