Laserfiche WebLink
} Applicatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herebyde to carry on business in the urisdictionai area of the San Jo2quin Local Health District t <br /> 77 <br />.F. Business Name (DBA)�1��, _�O 'YI ��� Address ®SSo, <br /> a Owner ,I <br /> Address � 5Q' <br /> J Firm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No. - 5> 61,6 Emergency Telephone No. E <br /> Contractor Licence No. 'I /f 9 <br /> L Applicants Narrie (Print) '+• IN: 1 Title L .ST — Date, <br /> Please check Applicable Category (1�7)and Fill in the Required Information <br /> 1. 12 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Ill Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity '!Gal., Weights & Measures No. <br /> Equipment Parking Address II <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored �l 4 <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location I� Test Date/Time I <br /> Q' <br /> 4. JS SANITATION PERMIT � i <br /> Job Addre 1 ocation �-�� <br /> I t Address ` <br /> Owner <br /> SEPTIC TANK ❑ CESSPOOIL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PK 41: <br /> ❑ TEMPORACRY WNEW ❑ REPAIR ❑ OTHER <br /> ,I: i <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t <br /> Type Construction — —� """' Disposai•Site — <br /> ILI <br /> No. of Units � F# Equipment Storage/Cleaning Location(s) � ) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30; 19 y <br /> Operator Name illi Where Certified i <br /> Plant Location N ' <br /> Plant Capacity II No. Units Served 1 e <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. Ei <br /> E] DRY CLEANING, Chemicals Useld/Amount/Mo . a, <br /> 1 hereby certify that Ili ave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances;state laws, and sand regul tions of th San Joaquin Local Health District. a <br /> . II - <br /> APPL)CANT'S SIGMA T URE X y. <br /> ' I' FOR DEPARTMENT USE ONLY <br /> ❑ EACH ❑ January 1 &Received By January 31^? ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY � ❑ PER UNIT uy PER SITE - - REMIT <br /> BASE'��I EXPLANATION BILLING REMITTANCE fi $ AMOUNT DUE CHECKED <br /> ff E DATE REMITTED <br /> DATAMOUNT <br /> hf <br /> I FEE `�:., <br /> %_ESS- <br /> PRORATION <br /> PLUS P� ' + <br /> PENALTY <br /> OTHER l�Ni t <br /> OTHER <br /> Date Receipt No. - P o. I suance ate Mailed Deliv red <br /> Received by .1I <br /> > X1601 E.HAZELTON AVE.,P.O.Boz 2009 STO KTON,CggyybQ11 <br /> 1 APPLICANT—RETURN ALL COFIES TO: ENVIRONMENTAL HEALTH PEHMITlSERVIG£S F 1 ` <br />