Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> M. S . qI -42 APPLICATION 9004- -I+ ,PWILLIPS <br /> (For Non-Transferable,, <br /> Revocable, and Suspendable) SEPTAGE <br /> ENVIRQ,NMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District" <br /> Business Name (DBA) F>-AU&AEBAc_w --e P� 7-2A Address 12Vb W, r__Ll../I ZT. L' ODS f G&. 55724119 <br /> Z.Owner Iz-, PI67_?_A Address-3�'�W Mel-64 sr,' <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone,No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) -7,_9x2Y P jb2-ZA Title. C•a• Date 2" <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30-19 - Disposal Sites <br /> Description(Make/Yr„ Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity. _ Gal., Weights &Measures No. <br /> - I <br /> Equipment Parking Address tl <br /> 2. ❑ PUMPER YARD <br /> i <br /> For July 1., - June 30, 19 a No. of Vehicles Stored 1 <br /> No. of Chemical Toilets Stored <br /> i <br /> 3. Rf PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. oql .C'.E. No. I q CoPJ?' <br /> 'Test Location bra 0 9 GE. JAWAI/T BE ACW69fest Date/Time � <br /> 4. ❑ SANITATION PERMIT u <br /> Job Address/Location <br /> -Owner Address <br /> DO <br /> ❑-SEPTIC TANK ❑ CESSPOOL' ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,19 4 I, <br /> Type Construction Disposal Site i <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6 ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> 3� <br /> Operator.Name Where Certified Y <br /> Plant Location <br /> Plant Capacity 'No Units Served i <br /> 7. ❑ LAUNDRY '.For July 1,.-June 30,.19 <br /> 1� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t ; 111 <br /> "_Vhereby certify that I have pr this application and that th work will be done in accordance with San Joaquin County --'r - <br /> ordinances, state laws, and r regulations of n o in Local Health District I ! <br /> APPLICANT'S SIGNATURE <br /> l 1' <br /> FOR DEPARTMENT_USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -13 January 1 &Received By January 31 ❑ July 1 &,Received By July.31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED I <br /> DATE DATEq REMITTED AMOUNT 1 <br /> FEE <br /> LESS <br /> PRORATION 1 <br /> I <br /> PLUS <br /> PENALTY <br /> l <br /> OTHER <br /> i <br /> OTHER <br /> Rec i by Date Receipt No. Permit No. Issuance Date Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />