Laserfiche WebLink
- <br />SEPTAGE 1 <br />Residence Tr- Apartment House 0 Commercial 0 • • Traile7 -CO674n <br />Motel 0 Other . <br />I Air <br />R.S. or R.C.E. No. <br />Test Date/Time <br />PACKAGE PLANT <br />OTHER <br />0 PER Sit E 0 EACH 0 PER UNIT Fee IS Due: 0 ANNUALl <br />DALE <br />BILLING <br />EXPi ANATION 1 <br />REMITTANCE <br />DATE REMITTED <br />REMIT <br />CHECKED <br />AMOUNT <br />AMOUNT DUE <br />0 July 1 & Received By July 31 <br />FOR DEPARTMENT USE ONLY <br />s-7 <br />.....yevived by Date Receipt No. Permit No <br /> APPLICANT—RETURN AU. COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />1 uance bate Malted Delivered <br />1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />OTHER <br />OTHER <br />0 January 1 & Received By January 31 <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />BASE <br />4L FEE <br />Applications Will Be Processed When Submitted Properly Completed. ne aUre I LI .21v.. <br />AP CATION <br />(For Non-Transle le, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />... LIQUID WASTE <br />Ap*plicatio is her e to carry Vness ' t jurisdictional area of the Localpalth trict <br />— <br />,'„ Business e (DBAI <br /> Add_,ress <br />`i Owner -E'. Address --'2,-- 9._./e'''Z_ <br />er y <br />f-) Firm Partners, Addresses and Telephone Numbers 7V.T.0205_,(Z a <br />-.-J <br />ga Business Telephone No. <br />Contractor Licence No. 3.0--S-i!---/e. < <br />Applicants Name (Print) .__J71--k- Title <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, __June 30, 19 Disposal Sites <br />'SIInstallation wfil S'er'sTiVr".' <br />Where Certified <br />A <br />Equipment Parking Address <br />0 PUMPER YARD <br />For July June 30,19 <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored <br />0 PERCOLATION TEST <br />R.S. or R.C.E. Name <br />Test Location <br />EVSANITATION PERMIT <br />Job Addres / ation , _„1--z_al <br />Owner ok..-t--t..4 Address <br />SEP IC TANK 0 CESSPOOL 11}eLEACHING FIELD M-SEEPAGE PIT <br />PERMANENT 0 TEMPORARY 0 NEW -REPAIR <br />of Units <br />ipConstruction <br />0 CHEMICAL TOILETS For July 1, - June 30, 19 <br />PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Equipment Storage/Cleaning Location(s) <br />Disposal Site _ <br />is <br /> Emergency Telephone No. Se517.— <br />Date _-(; <br />Operator Name <br />Plant Location <br />Plant Capacity <br />No. Units Served <br />7. 0 LAUNDRY For July 1, - June 30, 19 <br />SIZE.. 0 Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br />0 DRY CLEANING, Chemicals Used/Amount/Mo. <br />I hereby certify that I have prepared this , plication and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws it: a les and reg on- of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X eIT