Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. ) <br /> APPLICATION - <br /> .. ' ; (For Non Transterabte,Revocable,'and Suspendable) SEPTAGE - <br /> ENVIRONMENTAL HEALTH.-PERMIT <br /> LIQUID WASTE , <br /> Application I hereby made to car` on business in the jurisdictional area of the San Joaquin Local Health District...., <br /> L Business Name(DBA) .I>A f� ?�f I � �S _ 4Address �% �— �fie`'""—► <br /> eOwner - Address <br /> J Firm Partners,Addresses and Telephone Numbers <br /> 96 Business Telephone.No— 4G4G -9�-7 _ Emergency Telephone No. ^~ <br /> �-- <br /> Contractor Licence Na. Date _14 <br /> L Applicants Name(Print) T Title <br /> Please check Applicable Category(1-7)and Fill In the Required Information (y <br /> 1: ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July t, - June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> 'serial No. ' CAL.License No. CAL. License Renewal"No, <br /> :Capacity { t Gal.,Weights A Mea'su'res No. <br /> Lf1Equipment Parking Address <br /> 2. ❑ PUMPER YARD ( } i <br /> FIA.For July 1, June 30,19 <br /> � s f • <br /> 0 No.of Vehicles Stored <br /> I, , <br /> No.of Chemical Toilets Stored <br /> '3. []'PERCOLATION TEST <br /> R.S.or R.C.E.Name t R.S.or R.C.E.No. <br /> Test Location Test Date/Time 1 ' <br /> ' 4. SANITATION PERMIT' <br /> � f • , ?' `�� r6 � <br /> *J7MAJ� <br /> Job Address/Location k SSS`` Ownir'�� `1`Q - Address `F,70.190 <br /> -qa �P,f3Ta�Ul <br /> �'SEPTIC TANK ❑ CESSPOOL f 2LEACHII G FIELD"❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 141ERMANENT ❑ TEMPORARY ',.ti.G"IEW� t ❑ REPAIR ❑ OTHER I <br /> Q'CHEMICAL TOILETS 'For July,1,-June 30, 19 <br /> /pe Constructldn t Dis�osal Site �•"'�t` / n <br /> No.of Units t ; <br /> �EquiPtAenf!Stordge/Cleaning Locations) <br /> .__ <br /> 6. ❑ PACKAGE TREATMENT PLANT_ For July 1,;June 30, 19 t f' <br /> Operator Name Where Certified <br /> Plant Location ) �; i r • / <br /> Planf Capacity 1''r No;Units Served <br /> T. ❑'LAUNDRY For,0� 1,-Junes4 19 ` ,- 3' l t ,w <br /> SIZE; - P LesstThan 1,000 Sq'Ft.,' ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY C'L'EANING,Chemicals Used/A:mouFVMo_ <br /> � t . <br /> $1, •.[,hereby certify that I e prepared this applicatlo nd that the wa k will be done in accordance with Sart Joaquin County <br /> ordinances,state law6' n ations San uin It Health District:t ' <br /> 2PPI-ICANT'S SIGNATURE X i <br /> Y ' <br /> -FOR DEPARTMENT USE ONLY <br /> • '� .-'Fee is Due:❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 3t C)July t 8 Received By July 31 i <br /> i - REMIT <br /> r BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION j• ' �' DATE - - DATE REMITTED AMOUNT 1 <br /> FEErf t. 6 .. $ t <br /> LESS <br /> PRORATION } ts <br /> kPLUSPENALTYOTHERlie <br /> OTHERfReceived by Date Receipt No. PermitNo. ua Da Mailed Delivered- <br /> 1601 <br /> E.HAZELTON AVE.,P.O.Bo,c 2008' STOCI(TON,CA 96201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />