Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATIONS°'_ �� ` �ss <br /> • (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT MS•. a-1_.2¢ <br /> LIQUID WASTE HAIA5Et.l Rt-N wei=i1 c7F GP -T Llt,4M RD. <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> a Owner UwAgD Lvaay - Address S580 1EAST AXI;_=t4QZ HAYWARN,r_A 94-c,2- <br /> Firm Partners, Addresses and Telephone Numbers u5 <br /> a. Business Telephone No. Emergency Telephone No. (414)IS 8840-34009(412Mir) <br /> Contractor Licence No. <br /> Applicants Name (Print) WAL-MR_ E - C;uQ-TIS __ _ Title CIVIL E14C-,;. USA-'e_ Date �" I'1`97 <br /> Please check Applicable Category (1-7) and Fill in the Required Information 41,8 MIIZTNIEW PtriVZ^ 1_01>1 CA 9524CD <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) BUS, <br /> For July 1, June 30, 19 Disposal Sites _ r10Me_ <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. .0 PERCOLATION TEST M-Z -8_1-24- Z"re <br /> 011111Aer R.C.E. Name NAI—TEK f—= . CUV:Tl=) RO-of R.C.E. No. 1 �8 <br /> Test Location SEN QZ'Q 1,409T14 CIE GRAV"r- 1!2 V!)Test Date/Time 5"5— � CTEN- <br /> 4. ❑ SANITATION PERMIT OR TRACY)C� <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. 1 <br /> Home owner or licensed agent's signature certifiesthe following:"I certify that in t"performance of the work forwhich this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workmars campensatio:::mvs cf Car,fornii,. <br /> Contractor's hiring or sub-contrasting signor.-m certifies tWe `,3fiowing: -1 Certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compeusatico IaVbs of Caliturnia." <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, and rules and regulations of the San Joaquin Local Health District. '1 <br /> APPLICANT'S SIGNATURE X 2 J��� <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 /> BILLING RE I A $ REMIT <br /> BASE EXPLANATION DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE �47,670 / L4 AAA <br /> LESS VV <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER �( <br /> OTHER `J <br /> Received by Date 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 />