Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION M S - 8 7 <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio�r s hereby made to carry on(b�u'siness in the jurisdictional area of the San Joaquin Local Health District <br /> ,„Business Name (DBA) bAiLm$Aicm � r!AzzA Address /s <br /> a Owner 1. P/A ZZ/4 Address •�2��1�C I►„- LoD <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � Emergency Telephone No. <br /> Contractor Licence No. oe <br /> Applicants Name (Print) 2- Title �- Date Z -:0 <br /> Please check Applicable Category (1- and 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. 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. X PERCOLATION TEST <br /> P,-@w t R.C.E. Name I !7_r-rA 7-A- R.S. of R.C.E. No. <br /> Test Location Bt^V rHe6.. UT_> r Test Date/Time <br /> 4. ❑ SANITATION PERMIT yZ irp" <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 licensed agent's signaturecertifiestheWgwing:'lmtifythatinthepetto,alanceoftheworkforwhichthispermitisissu Shall not em <br /> ploy any per bull <br /> in such manner as to become subject to workman's compensation laws of California.' <br /> Contractor's hiring or sub-contracting signature certifies the following; -1 certity that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of California" <br /> I hereby certify that I have prepared s application and at the -or will be done in accordance with San Joaquin County <br /> ordinances, state laws re ul tions of the an Joaqui cal Health District. <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMO NT <br /> Ai <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> C <br /> OTHER <br /> Re ed by ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> A PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />