SU0007781 - Laserfiche WebLink

Home Browse Search

Applications Will Be Pr(. ed When Submitted Properly Completed.Be bus sign I no"Plaruauul ' fi x APPLICATION (For Non-Transfarable 'Re+rocable,and Susperedabla} SEPTAGE ENVIRONMENTAL HEALTH PERMIT LA_p 1—4 uQulo WASTE7 1"r'sk Application is hereby made to carry on business in the)urisdictional area of the San Joaquin.Local Health District �,��•�gA}, � A dress t?'Q �$� ��'1~I��KZS•G ✓�'2{?' ! Owner A rens � 2 _ Firm Partners,Addresses and Telephone Numbers ��' �Sg—337$ t 7�0 � _ �business Telephone No. _ Emergency Telephone No._ - _ aContractor Licence No. LApplicants Name (Print) W6=99: �'Title 1v r L I=taG1145k& Date Z—?—G-9.1 Please Check Apptir able Category(1-7)and Fill in the Required'lnfornnellbs 418 M E. I 'ZA f Loot Co.95Z440 1. 1:1 PUMPER VEHICLE PERMIT REGISTRATION(POR EACH VEHICLE) 9 For July 1, June 30,-19 _- Disposal Sites Description(Make/YT.,Color) Serial No. CAL.License No. CAL.License Renewal No. Capacity Gal.,Weights&Measures No- Equipment Parking Address 2. ❑ PUMPER YARD For July t, June 30, 19 No.of VehicJes Stored No.of Chemical Toilets Stored 3• X PERCOLATION TEST 14 SCZ%L a ' jot!� u R.C.E.Name C.E.No. A� Test Location`?t ��N1 f�WRY 12_GL1~MTest'Date/Time CA. 4. 11SANITATION PERMIT SAntil�xA'� Job Address/Location Owner Address 13 SEPTIC TANK 13 CESSPOOL 13LEACHiNG FIELD ❑ SEEPAGE PIT E3 PACKAGE PLANT ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER � s. ❑ CHEMICAL TOILEt'S For July 1,-June 30, 19 Type Construction + Disposal Site r No.of Units A �` $ Equipment Storage/Cleaning Location(s) n a. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 -- Operator Name Where Certified Plant Location No. Units Served Plant Capacity 7. ❑ LAUNDRY For July 1,-June 30, 19• - - -- SIZE: C3Less than 1,000 Sq. Ft_, ❑ More Than 1,000 Sq.Ft. �„Q ❑ DRY CLEANING.Chemicals Used/Amount/Md. � }Fosm>av�n,a.e.lleerraedageiars�rmtueeeehif;esdrarotlawtno;"1reAifythptintheprrslomwrlcenttAewa+kfpTWhichofpermitisisstRd,lshallnot anype an In such.manner as to become subject to lrorkmArfs cnmperaalion laws of Lallforrria." ' Cowraomr•a or sup-eommating algtrtltere mea.AAs lellpi411rrp: 'I Cer111tt that the peHoctnar►t6 Of the verk for which this pOrmli is issued.I shall employ persons sibbJect to wsrlim i s calapaltSatift i>rws of(;ANMia" I hereby certify that I'have prepared this application and that the Work will be done 16 accordance with-San Joaquin County ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. ` I 'APPLICANT'S SIGNATURE X FOR DEPARTMENT USE ONLY i Fee 19 Due:❑ ANNUALLY ❑ PER UNIT, E3 PER SITE ❑ FACIA •d January 1&Received By January 31 ❑ July 1 b Received By July 31 REMIT BASE E%PLANATION BILLING REMITTANCE 3 AMOUNT DUE CHECKED DATE. DATE �l � —REMITTED AMOUNT FEE 1 a ,p�f �. lw�� 7�Ll 2'"" 7 LESS -PRORATION ' PLUS PENALTY OTHER - - - OTHER v by Date ' Rece PlI mlt No. - - idsuanee Date Mailed Daliverad i Re 1 . -APF NT—RYTURN ALL COPIES TO: ENVIRONIMENTAE HEALTH PERIMIT/SERVI'M 1601 E.NIIMTON AVE.,P.O.90112009 gTOCKTON,cA 85241 +