Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT . <br /> LIQUID WASTE <br /> Applica ' is hereby r�lade ko arry on L{sine s.n the j is icti nal area of then, oaq Local ealth District - I <br /> rn Busine ame{bBA) ddress <br /> a Owne - Address <br /> L) Firm Partners, Addresses and Te phone Numhe <br /> aBusiness Telephone No. L � �(,�S Emergency Telephone No. <br /> Contractor Licence No. - 2 M. <br /> L Applicants Name(Print) r. Title - Date <br /> i s'�.c moi. . '+ - _ I <br /> -Plese'ch�ck Applicable 681e (1-7)andrFill in the Req d Informatlon r ; <br /> ` 1 , ❑ PUMPER VEHICLVPERMIT REGISTRATION (FOR EACH VEHICLE) <br /> `For;Ju y June 30,.19--2 Disposal Sites - --- <br /> ,Description(Make%YK,-Co1or)1\ <br /> Serial No:, CAL. License No. CAL. License Renewal No. <br /> Capacity + - � �' Gal'.,Weights &Measures No.. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD' t � <br /> For July 1, June'30,19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t <br /> 3. ❑:'PERCOLATION TEST t- t <br /> .R.S. or'R.C.E. Name R.S.or R:C.E, <br /> Test Location " Test Date/Time <br /> 4.- LTJ SANITATION PERMIT' <br /> ��// �-► T t t r ! <br /> Job Ad dre Lo at' �f , _`_ r7� Q <br /> Ow r - - A� ( Address�Z��, � i j <br /> L� SEPTIC TANK ❑ CESSPOOL LEACHING FIELD %-15E"EPAGE-'PIT—QTPACKAGE PLANT <br /> ®<ERMANENT ❑ TEMPORARY ❑ NEW �EPAIR ❑ OTHER .� <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ! (A <br /> Type Construction ` �- D'isposa+--Site�� <br /> No. of Units • Equipment Storage/bbaning LoG.ation(s) <br /> 6. 13 PACKAGE TREATMENT PLANT�Por'July 1, -June 30 19 i_ { <br /> Operator Name k: ~` s s r. -"""—Vlrh`ere-Certified f. j <br /> Plant Location v X. <br /> Plant Capacity $1, No. Units Serve e � —'; <br /> 7. C1 LAUNDRY For July 1, -June 30 59 '-- i- "e i ' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑More Than ;1;000 Sq. Ft:I E j g <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, l Vii, i ?• <br /> ada enYasi naturtrc ` i I y lr ! i <br /> Hameownerarlican <br /> s 9 g ertif+e9thefo,'tlnuv,ng;'`4certifythatintheper#orm�MCsottCs tl for vihicl?This pt?�mitisissued Isholnot Employ any person + <br /> in such manner as to become su?ject to larkr an`s cvri?pcns3+iorr Paws of C tCfor+l <br /> �..Contmety;'s hir;np or'sub ccrfYrar?'!ep Sitgnat6ra cer�l5i»; ;he ioSlatviny: 'i I ert•g ,.at i.rflte EitL,iI1dTCL�S ;itCtv�f r4Yhizth.F Permit em iGy t3erSGi?S 5tihj^cCi:G i'!f►f+(m3%5 mil"IC<<S?tiOl laws of.cu tt0➢fila.' y 1 t' n "r.� � IS:Istued,I Shall <br /> I hereby certify that,l have prepared tFa s pplication anc ithat_the work°will be done in accordance with San Joaquin County <br /> ordinances, state lamfs, and,' lep—lhuegu tion f the Safi Joaquin&A(-Health District. <br /> APPLICANT'S SIGNATURE X <br /> * -FOA DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER:UNIT- ❑ PER SITE ❑ EACH, ❑ January 1 & <br /> Received By January 31. ❑ July 1 &Received By July-31 <br /> REMIT <br /> BASE -EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE - - DATE 'REMITTED #. - - AMOUNT <br /> FEE 4 L1 <br /> LESS <br /> PRORATION _ _ ) <br /> I <br /> PLUS 9 <br /> PENALTY - - <br /> OTHER t € • i <br /> OTHER . . 5 <br /> Received by r Date Receipt No. Permit No. k - r Issuance Date Mailed Delivered- - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />