Laserfiche WebLink
Snyder Lithograph—Stockton,CA <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �� _ (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> Z>/ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) Address <br /> i Owner /12G�r/O 1�r/r�' Address 3SaSE Lc&'�er �ol 4444za4 . G.9 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Z?yrD/d L .:7792 Title ate "G" 90 <br /> Please check Applicable Category (1-7) and Fill in the Required Information 12 Z 9 ,l,o/ e'n'v,44 1✓�I�/ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) rTOG,��O/j I� )f 9SZt� <br /> For July 1, June 30, 19 Disposal Sites y 7 4L�fi <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 5d PERCOLATION TEST <br /> R.S. or R.C.E. Name h (, ?'b� R&P&6R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 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 /> 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 /> Homeowner or liognsed ag-nt's si nsture rertifiee the frAkr*dntm:"I—r—ft•h";-the of thnworl,.forvvhirh this permit is issued,I shall not employ any person <br /> in such manner as to become subject!o workr..a1; ca ripens:tto ta!^n..'r,; <br /> Contractor's hlrir,9 or sub-rontraadna ,;grriture cortdfic: +h- o,:r::;,:g. d,t iy the t hr!:,,e per(m;az;:.ce of the work for which this permit Is issued,I shall <br /> employ persons subject to workman's compensat,ou laws of Califofoia:' <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, an rules and regulations of the <br /> �San <br /> +Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X •�aC.d r. r ` � <br /> FOR DEPARTMENT USE ONLY <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received dy ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />