Laserfiche WebLink
`` '' APPLICATION <br /> Pw <br /> ` Non-Transferable,Revocable,and Suspendablos.."i" SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carWn business in the jurisdictional area of the San Joaquin Local Health District <br /> � <br /> Business Name (DBA) A PAR.�OIS9sB�✓5 Address F1780K ;4V_0 SYhw! 9S-Ad/ <br /> 61. <br /> i Owner Address 1 <br /> L <br /> Firm Partners,Addresses and Telephone Numbers <br /> Business Telephone No. 441,A- 9607 Emergency Telephone No. <br /> Contractor Licence No. sas-43,/3 <br /> Applicants Name (Print) Ft-0 y D WC7 01) Title EST/A*A"dP- Date 8-131-7 9 11 <br /> `Please check Applicable Category (1-7)and Fill In the Required Information lr <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -� <br /> For July 1, June 30, 19 Disposal Sites OI <br /> Description(Make/Yr.,Color) _C <br /> Serial No. CAL.License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights S Measures No. <br /> Equipment Parking Address r / <br /> r 2. ❑ PUMPER YARD V <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> L.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 /> LTest Location Test Date/Time <br /> 4.X SANITATION PERMIT <br /> Job Address/Location -234A80 Sd[t/[-ES WO y A CA m PO <br /> Owner F;Wan 'VOCE[_ Address !'AC Ala Dir At/6y fL/ye Al- 9S- A&,6 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD )4 SEEPAGE PIT ❑ PACKAGE PLANT <br /> X PERMANENT ❑ TEMPORARY Jff NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> LType Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - <br /> LOperator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> LSIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> L <br /> 1 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 regulations oft an aquin Local Health District. <br /> L APPLICANT'S SIGNATURE X 1000, I� <br /> LFOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT MPER SITE ❑ EACH ❑ January/a Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ` BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> y d AMOUNT <br /> FEE <br /> 6a, PRORATION PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> L <br /> OTHER <br /> Z <br /> has Racerved by Date Receipt No. Permit No. Issuance Dale Mailed Deli red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON, A 95201 <br />