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 f <br /> "-1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE r <br /> Application is hereby e tocarryon bust ineo in the ur sdlctional area of the an oaqu�in,L°�al H al h District <br /> HBusines Name DBA �....PLC: V y 9 L{ L 'Address��!�-f y Q_bnl <br /> a Owner �F_ E Y4 IN F\)NQ Address, r <br /> Firm Partners, Addresses a T pho a Numb"rs <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No.� ^x <br /> ate W Applicants � � - -. Title, � - <br /> Piease check Applicable Category.(1-7) and Fill In the Required,lnformation <br /> 1. ❑-PUMPER VEHICLE:PERMIT,REGISTRATION (FOR EACH VEHICLE) <br /> ! " <br /> '-'Fo�jJuly'L1 Jrune`30,/19 1 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. r ✓ CAL•.License Renewal No. <br /> Capacity___._..—.--- - ..Gal;Weights'8 -Measures �.�_ _ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Cf�'emical Toilets Stored <br /> 3. ❑ PERCOLATION TEST y <br /> R.S. or R JC.E. Name R.'S.or R.C.E. No. M <br /> Test Location Test gate/Time 4 <br /> 4. ❑ SANITATION PER IT <br /> Job Address cation �� <br /> Owner ' C- Address s <br /> ❑ SEPTIC TANK ❑ CESSPOOLEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT 13 TEMPORARY NEW f FFEPAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 _ _ sq. <br /> . <br /> ( <br /> Type Construction Disposal Site - i <br /> No. of Units J Equipment Storage/Cleaning Location(s) r r 3 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where'Certilied',`� n <br /> Plant'Location <br /> Plant Capacity { I No. Units Served I s <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ( I <br /> © DRY CLEANING, Chemicals Used/Amount/Mo. <br /> FTomavwnero■Rcensedagant'vsEgna;arar.^r;isoat>�f :!awiricerfifythatinthe performanceofthe work forwhichthis permit isissued,Ishall notemploy any person <br /> In such manner as t= become sub;ect io Iv.;rk;Zzr: cG -.ns:,iiar (av)s=st^a.itornia." ��•! € <br /> ContrCctor s hiring Cr ac:b-car�ie�!ing :.i3ns•.a;�zr ¢Gr.�drae"inv:rfJltovving- `,'I certif,that in the performance-15i"16 wcrk•for%vhich"tilis permit is issued,I shall <br /> employ persons subject to workmsr,'s ccmperlsaticr,jat" of iifcrrl o.` -> <br /> I hereby certify thal'i have prepared-this appjicatio nd"ttiat"fhe,' ork'w111-be done-in-accordance with San Joaquin County <br /> ordinance aws hd rules and re6latio Aft San J7' ujn Local Health District, <br /> j f <br /> APPLICANT'S SIGNATURE X <br /> I ' FOR DEPARTMENT USE ONLY- <br />. � .,:��� `u� � �, �--,, 1 <br /> Fee IS Due: ❑-ANNUALLY ❑ PER UNIT: ❑ PER SITE' ❑ EACH ❑ January 1 &Received By January 31 LJ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> «BASE EXPLANATION DATE -DATE REMITTED �. <br /> 2 AMOUNT <br /> FEE— �� 7 • A t <br /> LESS <br /> PRORATION <br /> PLUS F'{ <br /> PENALTY - - - - <br /> OTHER t <br /> ' Y <br /> OTHER .•F - - - <br /> x <br /> Received byate Re iriNo. '•Permit No, Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL T(01131 ES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />