Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign eApplication. <br /> APPLICATION <br /> (For Non-Transterable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT91 <br /> \L is t ! <br /> �h 0� <br /> LIQUID WASTE <br /> Application is hereby mAdde�to carry on bus' ess in,the jurisdictional area of the Sj J aquin Local Health District <br /> 0'' Address 1"i �Z �� �✓ 'f`.Z�� <br /> rn Business Name (DBA ! <br /> 4 Owner w.ti Address <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No ��� Emergency Telephone No- <br /> Contractor Licence No. Date <br /> L Applicants Name (Print) Titke I <br /> Please check Applicable Category (1-7) d Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 — Disposal Sites <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No, <br /> CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> ( <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 5 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ! i <br /> R.S.or R.C.E. Name r,- s R.S. or R.C.E. No. <br /> s <br /> Test Location : + Test Date/Time E _ <br /> 4. 0(SANITATION PERMIT - ' ft <br /> #+; <br /> Job Address/Location # <br /> r - Address <br /> Owner <br /> Of SEPTIC TANK CESSPOOL [Ir LEACHING FIELD SEEPAGE PIT 11 PACKAGE PLANT <br /> fig PERMANENT i ❑ TEMPORARY JS NEW!61 ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, i9 <br /> Type Construction ? Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) - S <br /> 6. ❑ PACKAGE T R EATMENVPLANT For July 1,`June 30, 19 Where Certified II <br /> Operator Name <br /> a � <br /> Plant Location y_ F <br /> :Cp , A. No. Units Served <br /> Plant, apaclty e a <br /> 7. [ LAUNDRY 'For'July 1, -?June 30, 19 <br /> SIZE: ❑ Less Than{1,000 Sq:, Ft_,. ❑ More Than 1,000 Sq. Ft. <br /> z , <br /> 11 05Y CLEANING, Chernicals Used/Amount/Mo. <br /> rfsif�ill`,�4'Irr idrflSHl4R, �q$Y�n�', .Sg �C;�:rel{��fll?+i^11;k�}CI'fCr'T7,1',.".LU;f�'rC[7Q?'IFfL�rfJtFlGlltt'eIC(lnrrnitlSl55�iP¢.ishallnote�mployi' j(perSOn <br /> 111�h ih t?1a �@r 1' tq p e�rle 5tfnr t 1v ry is a,r �C.atio I1 04 <br /> hii ri t "I-curlify that in thl performance of the work for which this permit is issued,15hall <br /> QM&Y pgram worl',n�6slaws of G'Wifornla. <br /> L <br /> .�....- . <br /> I hereby certify that I have epared this application and t t the wor ill be ne in accordance with San Joaquin County <br /> ordinances, tate lawjs, r I and regul sof�the oaqui oca Heal istrict. <br /> F <br /> APPLICANT'S SIGNATdRE X <br /> r " --tr-13,r lI <br /> FOR DEPARTMENT USE ONLY <br /> r ,.: j <br /> .S PER SITE `f❑ EAC#'I ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Feels Due: ANNUALLY ❑ PER UNITa�. REMIT <br /> kg � �� - � F�BILL•lNQ 4 REMITTANCE $ AMOUNT DUE CHECKED <br /> 1E <br /> l t I BAS XPAMOUNT <br /> LANATION'� .DA r_ DAFE RElv14TTED <br /> f. <br /> FEE – ' <br /> LESS <br /> PRORATION <br /> I , <br /> PLUS . <br /> PENALTY r <br /> OTHER <br /> _ OTHER <br /> Received by pate '. Receipt No. _ r, -_Permit No. ssuan a Da Mailed DeliveredJ. <br /> APPLICANT—RETURN ALL COPIES TO:- 'ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> t6D1 E-HA2ELT0 - -O.Box 2009 STOCKTON,CA 95201 <br />