SU0013416 - Laserfiche WebLink

Home Browse Search

Applications Will Be Prock J When Subfinitted P:,operly Completed. Be Sur, Sign The Application. - APPLICATION (For Non-Transferable, Revocable, and Suspendable) SEPTAGE ENVIRONMENTAL HEALTH PERMIT LIQUID WASTE Application is hereb made to carry on business in the jurisdictional area of the San Joaquin Local Health DistrictST.0 Ct til ,1.r � �tr D Z L 0 W4 Iv'C E(Z - wBusiness Name (DBA) - 1QN _�r1LL SErS}lNC. _ _ Address __---.- - A- c, -- C , C, f�IJC ��N Address - - - -- -- - zQ Owner.- -- - - - --- - - J Firm Partners, Addresses and Telephone Numbers _- - - - - aBusiness Telephone No. _-��" �D�3Z--- --- - --- --- Emergency Telephone No..---- ----------- -- a - - -- Contractor Licence No._ --- - - - IS p _a S a wo G g Applicants Name (Print) C- C�RNtE _- __ Title --� k- • - Date Please check Applicable Category (1-7) and Fill in the Required Information 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) For July 1, June 30, 19 _- Disposal Sites _ -- -- -Description Make/Yr., Color) - Serial No. --_ _ _ -___ -___ CAL. License No. _ --- -___ __ CAL. License Renewal No. Capacity -_ Gal., Weights & Measures No. _- — -- --- --- - Equipment Parking Address 2. ❑ PUMPER YARD For July 1. June 30, 19 No. of Vehicles Stored No. of Chemical Toilets Stored - 3. K PERCOLATION TEST 1 ^� R.S. or R.C.E. Name C . C��NCS lid N G-'--- R.S. or R.C.E. No. h ---- Test Location IL-T711 F�`�N� �� P Test Date/Time - - -- - -- -- 4. ❑ SANITATION PERMIT P m TO M A'TU Job Address/Location - - --- --- -- - - - Owner Address-- --- - ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER J 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Type Construction Disposal Site - --- -- — - No. of Units Equipment Storage/Cleaning Location(s) - -- -- - - - 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - _ Where Certified Operator Name Plant Location Plant Capacity _ No. Units Served - 7. ❑ LAUNDRY For July 1, -June 30, 19 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ❑ DRY CLEANING, Chemicals Used/Amount/Mo. I hereby certify that I have prepared t is aa ion and tha h w rk will be done in accordance with San Joaquin County ordinances, state laws, and rules a e u . n the San a ui ocal Health District. APPLICANT'S SIGNATURE X FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C3 January 1 &Received By January 31 ❑ July 1 &Received By July 31 _. ---- -- REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE L C__ LESS PRORATION - PLUS n/ PENALTY /�/ - - - - - --- - - - -- - - - OTHER OTHERJi C. _ W� Received b5 jDate Receipt No Permit No Issu ce to Mailed Delivered .moi ir�T-HfnIBC�91 I COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ NAVE.,P.O.Boa 2009 STOCKTON,CA 95201