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 /> J 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) 5clumbuch & PIUZZ4 Address 323 W Elm SII—OdI 1W, <br /> a Owner UE11 ( A0t1MbQCh Address <br /> J Firm Partners, Addresses and Telephone Numbers Telmy Yiazz-a Some <br /> o. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) f Title R, C.E Date I <br /> Please check Applicable Category (1-7) 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. Dd PERCOLATION T ST <br /> R.S. or R.C.E. Name 0, R.S. or R.C.E. No. I (� <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT -1eCt*811526 cfA G <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 signature ee►tifhsthe fettowinp''9 eerfiPt that in the periormanceet the work tot which this permit is issued.I shall not employ any person <br /> in such manner as to become subject to wcrkmali s compensaticn Iasis of Cafitornia." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify 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 Caiitornia." <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, arA rules an regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE �� � a�7- AUf ((JVLaQ6E 11.6, SPH) <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 eceived By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE REMITTED AMOUNT DUE CHECKED <br /> DATE t AV AMOUNT <br /> FEE Q o { O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY JJ <br /> OTHER <br /> OTHER <br /> T-7 -7q L4 4 <br /> Received 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 />