Laserfiche WebLink
y Applications Will Be Processed When Submitted Properly Compieiea. neoury _.n• <br /> APPLICATION <br /> V f(Fo Nan-Transferable,Revocable, and Suspendable) SEPTAGE , <br /> ENVIRONMENTAL HEALTH,PERMIT ` <br /> LIQUID WASTE y ' + ' i `-_4T. <br /> Application is hereby made to carry on business in the Jurisdictional area of the�5a�oag�suin L� ea eth District <br /> ` =k> .—Address <br /> CO'Business Name (DBA) - <br /> Address <br /> a . <br /> _ _ �,. � _ <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> cBusiness Telephone No. T R . <br /> Contractor Licence No. `Z'S�'3 - Date : <br /> Title <br /> L Applicants Name (Print) <br /> Please check Applicable Category.(1-7) and Fill in the Required IMormaiion N 4. ..ki,. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30.19'_: <br /> Disposal Sites - <br /> Description(Make/Yr., Color) - CAL. License Renewal No. <br /> _Serial No. CAL. License No.. - � <br /> _ .. _ <br /> Capacity Gal.,Weights &Measures No. x <br /> Equipment Parking Address �- <br /> 2• ❑ PUMPER YARD <br /> For July 1, <br /> June 30, 19 ; <br /> _ <br /> No. of Vehicles Stored f _ <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E. NO <br /> R.S. or R.C.E.'Name Test Date/Time ' r <br /> Test Location ) ' ` <br /> 4. ' SANITATION PERMIT <br /> Job Address//LLoca�tion <br /> Owner I—Ale-LIE '' Address <br /> ❑ CESSP.00L 19°LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 SEPTIC TANK ❑ NEW REPAIR . ❑ OTHER s <br /> 1 1 <br /> `PERMANENT ❑ TEMPORARY r # <br /> 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t <br /> r <br /> I Type ConstDisposal Site <br /> ruction <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19. <br /> 1 } <br /> . Where Certified, <br /> Operator Name i <br /> Plant Location 5 No. Units Served ( € <br /> Plant Capacity t <br /> 7. C1 LAUNDRY For July 1, -June 30,-19 <br /> SIZE: ❑ Less Than 1,000 5q. Ft., ❑ More Than 1,000 Sq. Ft.-"k-- <br /> 0 <br /> t.❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> }tdmeownsrorliCBrtsed8ga>St'ssignettAece►tH3n5thefoRowirtp:"lcertiivthatinthepe ormanceofthe warkfor which this permitisissued ishallnotemployanypersan <br /> in such manner as to became subject to wi)krn n'S comliarsatio+t laws of Ca ifrirr►a. f <br /> Contractor's hirirt$ nr sub-contracting signsture certifies trte`fahowirig: "I certi;yfhat iR the.perlortnance of Ihe,work.tar--which this permit is issued,I shall <br /> employ persons subject to workman's compef;Sals-at+laws of California." - <br /> r :-o <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, a rules and reg lotions of the San Joaqui Localiealth District. <br /> APPLICANT'S SIGNATURE X . .,., <br /> t l f I t <br /> iJ w;�-FOR-DEPARTMENT-USE ONLY,. T <br /> .Y . <br /> Fee is Due' ❑ ANNUALLY ❑ PERUNIT © PER''SITE ❑ EACH ❑ January 1 &-Received By January 31 ❑ July 1 &ReceivedREMIT <br /> uIy 31 <br /> • t i „�BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 'BASE EXPLANATION . DATE DATE REMITTED- - 1 AMOUNT <br /> FEE <br /> LESS � <br /> PRORATION r <br /> PLUS r'. i -PENALTY- <br /> OTHER <br /> OTHER s. `, ..r _1 <br /> `E 4 <br /> lssuanCef Date Mailedt Delivered <br /> Date Receipt.No. ermit No <br /> Received by _ .0 r- RVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ' STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES TO: a ENVIRONMENTAL HEALTH PE '� <br />