Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r Non-Transferable, Revocable, and Suspend3oK, SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA) gClt,1 p'Yl �.?UL11 rG l rc Z ZG —Address_'1-tea E I Y7l SIt. �L+Cr{'1 t C€' <br /> aOwner T,z.r I`y Address 5c' <br /> Firm Partners, Addresses and Telephone Numbers J EY F&-C 11 1 rt - G.- ,,..1 a <br /> iBusiness Telephone No. �o I Emergency Telephone No. <br /> 11 Contractor Licence No. <br /> �Applicants Name (Print) l &rr-w F,{,.t ZZQ `. le —,�1' � C 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.,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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. )9 PERCOLATION TEST _ <br /> R.S. or R.C.E. Name T(Lr ; i, sc L.Zr-t A.S.or R.C.E. No. <br /> Test Location J�c U<-,). •' t I 9 S 19 E. L1012.04A le fear nate/Time <br /> 4. ❑ SANITATION PERMIT4P?03'7 Lam' Cv '16 2.4-0 vr.'f?�_ <br /> J. is-W 4, 4,. ?..y <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <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 <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. <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, an as and regulations of the San Joaquin Local H alth District. <br /> APPLICANTS SIGNATURE �GyV/L TE<.ro � <br /> A c7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 d Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> \ C AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ID <br /> Received O -y Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2005 STOCUON,CA 85201 <br />