Laserfiche WebLink
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 /> ENVIRONMENTAL HEALTH PERMIT MS_ <br /> LIQUID WASTE «b0n W Sc Hk,`-T:E Q> <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 7't'_AC1' Vii'+' <br /> Business Name (DBA Address <br /> z Owner Address q- r4- AYFj E Lb 1�R 1VE FREEMOhI'iT:A 536 <br /> J Firm Partners, Addresses and Telephone Numbers 'C4.1S, C-5-7 -- 5250 <br /> a. Business Telephone No. — Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) WAL'�FR C3U R'S1S Title C IV IL- Et�1C,11 ER Date 4- "'87 <br /> Please check Applicable Category (1-7) and Fill in the Required Information 418 MA-rT Ar=W �l/�ZA�L_e_)ta. J C N 952¢0 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) %15.PtA0t4C- . (109) 94-le's-'795-0 <br /> For July 1, June 30, 19 Disposal Sites "ME 1>"OTA 1E ( Z09) S4,5-g-(59 <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. % PERCOLATION TEST �Y1S-S� (� �rC�- S 1 <br /> R.C.E. Name WAL_'«2L E C )9_' 1 5 RMGM R.C.E. No. C_ I IS84 <br /> Test Location 13000 W .5CH U L-TE 2-r->, Test Date/Time R7 <br /> 4. 1:1 SANITATION PERMIT7VZAc'Y �^' 37(O oaeeC0 13 zr►,y <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 /> Home owner or licensed agent's signaturecarlifiesthetnnovving:"f certify than In the per!ormance ofthe work for which this permit is issued,I shall not employ any person <br /> in such manner as to become Sutject h1'::oti;rna;t's corri0ensalion <br /> Contractor's hiring or sub-C;".tR3^P y;G siyn3t.:re corti'fit•s the fa(lomng: I ceriify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's zotnpeasatiou lawb of California." <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. <br /> 4 <br /> APPLICANT'S SIGNATURE �C Y��„ J 11r /I a 7 <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 REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATIONPLUS �y [ <br /> PENALTY � <br /> OTHER <br /> OTHER <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 />