Laserfiche WebLink
- -!r- <br /> Applications ill Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> /"M Bbl?, APPLICATION <br /> D <br /> / S J/J Ix,7 (For Non-Transferable;Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTHY ERMIT <br /> j LIQUID WASTE <br /> Application r made t rry on bu ess in thejurisdictional area of the San Joa um Lo I Health trict <br /> Addre <br /> w Business BA)Nam I <br /> i Owner--- Q .;7 -Address _ <br /> a - <br /> 0 Firm Partners,Addresses and Telephone Numbers - <br /> a Emergency Telephone No, <br /> < Business Telephone No. <br /> Contractor Licence No. <br /> Date - -- <br /> Applicants Name(Print). �l. ___ TItEs -. <br /> 1 <br /> � I <br /> Please check Applicable Cetegory,�1-7)and Fill In the Required Inforrnation ,t •� ;L.i :U „�7 Y? ;i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 —Disposal Sites- <br /> Description(MakeNr.,Color)_- <br /> .�I. CAL. License No. CAL-License Renewal Na. <br /> Serial No. -- - <br /> Capacity-- H Gal.,Weights&Measures No.—___ ._ - <br /> Equipment Parking Address _._.. <br /> 2. ❑ PUMPER YARD _ <br /> For July 1_r:_ --_.June 30, <br /> No.of Vehicles Stored I' -- -- <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name II 4 R.S.or R.C.F. No. <br /> Test Location — -., - Test Date/Time <br /> 4. ❑ SANITATION PERMIT ! <br /> �� <br /> Job Address./Location <br /> • r' <br /> • r <br /> Owner ❑ I�` EPAGE PIT <br /> XAddress. '0PACKAGE PLANT <br /> SEPTIC TANK CESSPO' L' EACHING FIELD SE <br /> ❑ PERMANENT❑ 13 TEMPORARY TEMPORA ❑ NEW p(�'REPAIR ❑ OTHER l l <br /> ap - <br /> 5. CHEMICAL TOILETS For,,July 1,-June 34, 19__.__ •.: r <br /> Type ConstructionIN Disposal Site _- <br /> y - - <br /> No.of Units __ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT Pr -- <br /> ILANT For July 1'.--June 30, 19.__. <br /> � <br /> Operator Name • 111, _1 -- Where Certified -- <br /> i <br /> Plant Location 0 <br /> Plant Capacity_ .-r—.---. No. Units Served '4 <br /> 7. ❑ LAUNDRY For July 1,- Une 30, 19 Y� <br /> SIZE: � ❑ Less <br /> (Than 1,o0o Sq.iFt_ ❑ More Than 1,000 Sq. Ft <br /> ❑ DHomeo'vneroricensadneelm'ssad/lur,,Used/Amount/Mo, �� �rng rt , N :,..�:tr..cnftl,e;1 rY,fol, ,njchtbispermitisissut'd,Isba!1no;employanypIIrsnn <br /> s c2 fi +,� > r <br /> ir•such manner as to <br /> Controcmr's hiring or suS-canlcactir,s acture daruf es the foila+�v ng; vvernly ihat in thZ perfts rtance ofit)e tivork'er which this pe-nit is issued,I sha;l <br /> employ persons subiect to workman's cb:r:pvrsaftn Iflw.s o;californi2 <br /> I hereby certify that jhave��, prepared this application and that the work will be done in accordance with Sari Joaquin County <br /> ordinances,state lawsand and regulati of the Joaquin Local Health District_. . <br /> APPLICANT'S SIGNATURE X <br /> -- FOR=DEPARTMENT-USE <br /> — Ht e — <br /> N S (; eceived By January 3'. ❑ July 1&Received BY Jury 31 <br /> Fee Is Due: O ANNUALLY ., ❑PER UNIT ❑ PER SITE' D,.EAC -- T <br /> -$ <br /> REMIT <br /> REN: AN � AMOUNT DUE � -CHECKED <br /> BASEL EXPLANATION �---. BDATEG ' S A. _ REMITTED AMOUNT- - <br /> �...' _ �O <br /> LESS t <br /> PRORATION - .i.... <br /> _- <br /> PLUS <br /> PENALTY _ - -- <br /> OTHER <br /> OTH£R Ali <br /> I <br /> Received by Data .Receipt No Perm,t No. issuance Date Maled Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIROIJMENTAL HEALTH PERMIT CES• 16o1 E.HAZE T0N AVE_,P.O.Box 2009 STOCKTON,CA 85201 <br />