Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. U <br /> . . ►�: ` ' .�:3 <br /> 4 _ (For Non-Transferable;Revocable;and Su spendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb made to carry on b sin sin the juri ctional area of th,,,,�an Jo wn Local Health Dist ' <br /> OF Business Name (DBA) 4);D-QA ddress —0, ���'�„!�„ <br /> z Owner Address <br /> j Firm Partners, Addresses and Tel hone Numbers <br /> CL <br /> Business Telephone No. _ � � Emergency Telephone No. <br /> Contractor Licence No. - <br /> L Applicants Name (Print) Title %( `t-a- .,,Date <br /> Please check Applicable Category(1-7) and FIII in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 44 n <br /> For July 1, June 30; 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> r Serial No. R CAL. License No. CAL. License Renewal No. i <br /> Capacity Gal„ Weights & Measures No. <br /> Equipment Parking Address s <br /> 2. ❑ PUMPER YARD ('r <br /> For July 1, -W June 30, 19 ` - <br />( No. of Vehicles Stored { - <br /> No. of Chemical Toilets,Stod <br /> PEre <br /> 3. ❑ RCOLAfiON-TEST <br /> R.S. or R.C.E. Name 1 R.S. or R.C.E. NO. A s <br /> TestLLocpion a Test Date/Time <br /> 4. L=TSANITATION PERMIT <br /> Job Address/Location Z"\ <br /> Owner CAdt 67Address�e27 <br /> C'SEPTIC TANK 11 CESSPOOL. BLEAGNING FIELD OISEEPAGE PIT:, ❑ PACKAGE PLANT <br /> 9-15'ERMANENT a=❑ TEMPORARY • - -BINEW'Z T ) � x ❑ REPAiR— ❑-OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 � rA <br /> Type Construction ° Disposal Site r +�' <br /> No. of Units }”^Equipmeni Storage/GlOaning Location(s) ___ s - f i f`• ^� <br /> (+>•:' .,yr...� 5 - �.3s��r4:}S i <br /> k 6. ❑ PACKAGE TREATMENT PLANT�For'July_11rte,;';lune 30, 19?• j <br /> Operator Name �" 1 = Where Certified <br /> r> - <br /> Plant Location 1 <br /> Plant Capacity l `"` No. Units Served <br /> F 7. ❑ LAUNDRY For July 1, -June 30, 19 t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounNo.f - f <br /> I I hereby certify that I h vp prepared A.S application a that the rk'WM'be done in accordance with San Joaquin County <br /> ordinances, state law n les and_ re' ations&7lAan Jo in ocal Health District. f r <br /> APPLICANT'S SIGNATURE 1 ' <br /> ' F <br /> FOR DEPARTMENT USE-ONLY I <br /> : .. s <br /> Fee Is Due: ❑ 'ANNUALLY ❑ PER=UNIT' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31, July 1 &Received By July�31 <br /> BILLING REMITTANCE $ <br /> BAi.� i REMIT <br /> a- SE EXPLANATION AMOUNT DUE CHECKED <br /> DATE PATE REMITTED 't AMOUNT <br /> FEE i r� <br /> Y ' <br /> LESS <br /> PRORATION § - <br /> PLUS <br /> PENALTY <br /> Ali <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. <br /> .a - Isgiudn?d-Dait Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SEAvicES 11601 E.HAZE E.,P.O.Box 2009 - STOCKTON,CA 951 <br />