Laserfiche WebLink
„Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION y <br /> YS (For Non-Transferable, Revocable,and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby ma a to car on busline ipn theEk, dirctlonal area of ttSaann Joaquin�oca�eallh District <br /> y Business Name (DBA) �(� tL�_ MM.M.L1J�C C)E:✓Address�3J_lJ��+ ��� <br /> iOwner L—IP _�,_ 1 - �L Address—. — <br /> 9 Firm Partners, Addresses a d Telephone Numbers --- ----- <br /> iBusiness Telephone No. g �.� - Emergency Telephone No. <br /> Contractor Licence.No.. .� -- - <br /> -- <br /> 11 Title ���, � <br /> Applicants Name-(Print) I E E �� ��L ,. Y : - Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. -❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) 1 <br /> For July 1, J June 30, 19 - Disposal Sites - <br /> Description(Make/Yr.,Color) <br /> Serial No. _CAL. License No. I ,a r CAL.Li�nae Renewal No. <br /> Capacity--j_— --Gal;Weights-&-MeasuresiVO <br /> 131, <br /> -=1 <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 <br /> R.S.Or R.C.E Name __ R.S.or R.C.E. No. <br /> Test'Location Test Date/Time ___... <br /> 4. ❑ SANITATION PERMITZI <br /> Job Address/LOcat op ra <br /> Owrier . _ Address S IN YV E -=7 'f <br /> F C 6EPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ PACKAGE PLANT.. <br /> ~ SEEPAGE PIT t �i <br /> PERMANENT ) ❑TEMPORARY I KNEW ❑ REPAIR ❑ OTHER �.. <br /> Ski 0 CHEMICAL TOILETS For July 1, June 30, 19 <br /> r • <br /> Type Construction Disposal Site <br /> - - <br /> No.of Units _ Equipment Storage/Cleaning Location(s) ) ;r <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. ...1f <br /> fl DRY CLEANING,Chemicals Used/AmounVMo. <br /> 3 I hereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin County t r; <br /> ordinances, ted�rulesa ons o he Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATU <br /> 1 <br /> FOR DEPARTMENT USE ONLY r <br /> t1 <br /> 1 Fee Is Due: ❑ ANNUALLY C1 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 f ❑ July I &Received By July 31 r <br /> t - <br /> my 1 REMIT �. <br /> ! <br /> EXPLANATION BILLING —REMITTANCE I S AMOUNT DUE CHECKED <br /> A <br /> BASF DATE DATE REMITTED - <br /> AMOUNT r <br /> FEE <br /> LESS <br /> P1 r <br /> ` PENALTY <br /> t/ I <br /> 7 <br /> i OTHFR <br /> -Received by + - MDate Rtcelpt No- . / f Permit Nr,z�1 - 1 Iss ante to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENv1110N11ENTAL HEALTJM PERMIT/SERVICES ”'1601 E.HAZELT E.,P.O.Bo=2009 STOCKTON,CA 95201 <br />