Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> l APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> I LIQUID WASTE <br /> Appiicat on is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yFBusiness Name (DBA �r` n 0;_q_-cam e„r+i e & L n ct1r�l­� . Address 46 / rH3 ra��+fiLane ' <br /> a Owner m - . ePE)n-aid _ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business-Telephone No.. q 31.--.0-4 9-7 -_ Emergency Telephone No._ 9.5 7-4 2-7 <br /> Contractor Licence No. . <br /> LApplicants Name(Print) Title, nT rr3 PT- Date 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information ,r _ <br /> 1. © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) cc- <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 /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <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 S <br /> 4. ❑ SANITATION PERMIT I <br /> Job Address/Location <br /> Z) .+ ! <br /> Owner r Address " ; <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGEaPLANT W '. <br /> ❑ PERMANENT ❑ TEMPORARY NEW A REPAIR ❑ OTHER 01 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site I <br /> No. of Units Equipment Sforage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 a <br /> Operator Name Where Certified <br /> Plant-Location 'nl J\A <br /> Plant Capacity No. Units Served 1 <br /> 7. ❑ LAUNDRY For July 1,i June 30, 19 # u <br /> SIZE: ❑ Less Than 1,000 5q. Ft., ❑ More,,Than 1%000 Sq: Ft.,�t�' i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.��` L <br /> I hereby certify that I have prepared this application and that the workw I be done in accordance'with San Joaquin County <br /> i ordinances, state laws, and.rulasand reg ulati f the San Joaqu' 'L al Health District. <br /> APPLICANTiS SIGNATURE.. - <br /> r a <br /> _ FOR DEPARTMENT USE.ONLY <br /> Fee Is Due: ❑.ANNUALLY; ❑ PER UNIT ❑ PER SITE ❑ EACH ❑j'January 1 &Received By January 31 ❑ July 1 S Received By July`31 <br /> 1 I k REMIT <br /> . - BILLING REMITTANCE $ . <br /> BASE Jr.- EXPLANATION AMOUNT DUE CHECKED <br /> �. DATE DAj E - REMITTED AMOUNT <br /> LESS + _ <br /> PRORATION - <br /> PLUS - <br /> '`' PENALTY <br /> OTHER x <br /> OTHER <br /> - r - <br /> Received by Date Receipt No� Pehwft N6 Issuance Date Mailed Delivered <br /> APPLICANT' RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTOM AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />