Laserfiche WebLink
M`lFllwouVna nm vc r.wcanc.. •...cn vwumwv•,vpv..� vv..y.w w... �.. .,�... .., ..y.. ...- '.,.,."--"-'.' <br /> M. 5. 9 2_ AP'P'LICATION L_ iJ i -L <br /> -rr'or Non-Transferable,RovocOMe,and Susperidabrall SEPTAGE y'Z 14- <br /> ENVIRONMENTAL "EALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area oft% Joaquin Local Health District <br /> F Business Name (DBA) ��111.AU bCe_W L� AddressW SIA ST 1 TGA 5Z� <br /> Owner 'T'1=RT+.Y ?1=7 _. ___ Address <br /> aass1 Del w• ELM T,—>L.1 <br /> g Firm Partners, Addresses and Telephone Numbers -_✓G!�Y __ _ -____ <br /> iBusiness Telephone NoEmergency Telephone No. <br /> d Contractor Licence No. - <br /> Applicants Name (Print) TE PRY -EbtiZ Title Date ---- <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. 11 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. o Chemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S.Or Name 'TERRP <br /> Y IeZZ .EA R.S. or .0No. �I(y <br /> Test Location _4 7-7 7 W. RAY RSP, Test Date/Time — — <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner _ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL • ❑ LEACHING FIELD 0 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 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 /> pr 4 kP C) <br /> 14 <br /> X12 1, 3C <br /> I hereby certify that I have prepargd'this application an that the work will be done in accordance witff 9Ca u*��2 ) <br /> nty <br /> ordinances, state laws, an l nAkd regulations of an Joaquin Local Health District. REC(�EIVF Vi <br /> APPLICANT'S SIGNATURE XI -- <br /> 2 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ,� AMOUNT - <br /> FEE - — -- - - <br /> PROIRATION -- --- -- <br /> PLUS <br /> PENALTY -- <br /> OTHER <br /> OTHER <br /> --- - - - <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> FNVIO/1NYFNTAI HFALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 9520 — <br />