Laserfiche WebLink
Applications Will BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. N <br /> APPLICATION _ <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 13( - (-7 o_oo <br /> Application is hereby,�made etta carry on business in the'uLnsdictional area oft a San Joaquin Local Health District <br /> yBusiness Name'(DBA) .� � / Address <br /> z Owner A Address <br /> Firm Partners. Addresses and Telephone Numbers o- <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 164S Title d %AA-rCZ - Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites Ca <br /> Description(Make/Yr., Color) �I _ _Y <br /> Serial No. t CAL. License No. CAL. License Rene it No. <br /> Capacity Gal., Weights &Measures No. i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD o <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 I <br /> 4. SANITATION PERMIT 'p <br /> Job Addr s/Location e=V.r O <br /> O�wnr 11�r3CL�i�vl �� Address •®�$a 1�s�' .S��1J � ✓ 1 {� <br /> ]�!;�SEPTIC TANK ❑ CESSPOOL �EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> LI PERMANENT ❑ TEMPORARY VIEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I <br /> Type Construction Disposal Site <br /> No. of Units Equipment-Storage/Cleaning Location(s)--- <br /> 6. ❑ PACKAGE TREATMENT PLANT ForlJuly 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 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. V) <br /> L .. C <br /> I hereby certify that I have prepared this application and that�nLocal <br /> will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and regu `tions of the an JoHealth District. <br /> APPLICANT'S SIGNATURE X A �4 <br /> FOR DEPARTMENT USE ON Y <br /> Fee IS Due: ❑ 'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - a ary 1 8,Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING R E REMIT <br /> BASE EXPLANATION PATE A�AN <br /> REMITTED AMOUNT DUE CHECKED j <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION_ <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit%o. NI uan a ate fled Deli erect <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1fi01 E.RAZELTO oK 2009 STOCKTON,CA 9520011 t� <br /> r t /J 1 <br />