Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> s � ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> c Application is here y made to carryon business in the jurisdictional area of thea an Joa uin Local Health District <br /> Business Name (DBA) A PIS_>d r TR-A_ Address_F,0._ xJ <br /> aOwner F .. Address <br /> Firm Partners, Addresses and Telephone Numbers Q <br /> m Business Telephone No. q&� — �1�a7 _ Emergency Telephone No, I <br /> Contractor Licence No. �i UOW <br /> �Applicants Name (Print)�_-r_"h4�+�: i Yi/1 S Title 15g 77t7 Date_ `� � R 2 <br /> Please check Applicable Category (1-7) rand Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> . For July 1, June 30, 19 Disposal Sites <br />### Description(Make/Yr., Color) <br /> Serial No. �. _ C"-'CAL. License No. CAL. License Renewal No. <br /> Gal:(Weights & Measures No. <br /> Equipment-Parking Address �. r <br /> 2. ❑ PUMPER YARD 2 <br /> For July 1 �`Juile_30,`19"'%_:�', <br /> No. of Vehicles Stored. ' <br /> No. of Ch'emicai Toilets Stored��' <br /> 3. ❑ PERCOLATION TEST: <br /> R.S�4or R.G.E-. Name*-. -ks. .: R.S. or R.C.E. No. <br /> Test Loca ' Test Date/Time <br /> 4. Er SANITATION PERMIT <br /> -Job Address/Location IBJ <br /> Owner 6►_9_ _LAuj .z'u, E Address L� o <br />{* ❑ SEPTIC TANK ❑ CESSPOOL OLEACHING FIELD 2-`SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 2 REPAIR - ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> I 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 /> E; 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 /> t - . <br /> I hereby certify that I ha prepared this application, d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules an gula ' s of e S n Joaquin Local Health District. <br /> APPLICANT'S_qIrl`JAMI IP1=X <br /> f FOR DEPARTMENT USE ONLY <br /> j <br /> Fee Is Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 { <br /> REMIT <br /> l <br /> BILLING REMITTANCE $BASE- - EXPLANATIONS AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE It <br /> i LESS <br /> PRORATION <br /> PLUSu p - <br /> PENALTY <br /> I <br /> OTHER 1 <br /> / 1 <br /> OTHER '.� •..x - "'" <br /> �r- <br /> �(oC�� O <br />. - Received by Date - Receipt No Permit No Issfiancd Dale Mailed Delivered ' <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - 'STOCKTON,CA 95201 <br />