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 /> Applicati n is h reby ads to carryon business in he jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) • a et �� � <br /> Address 1 tit? ` <br /> z Owner <br /> F , <br /> c >? _ +K4ddress <br /> J Firm Partners, Addresses alldle hone Numbers <br /> a Business Telephone No. <br /> a Emergency Telephone No <br /> Contractor Licence No. ot-C dr r sit t y. ; L <br /> Applicants Name (Print) ,w1 G t Title Uw 'aw Date 7 I 1 <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 /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 _ µ <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 <br /> 4. ❑ SANITATION PER T r <br /> Job Address/ ovation b 1.4'V P A Wo . cA <br /> Owner sc. <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER ©, <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 0 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 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 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home ownaf or licensed agent's signatura cartif3as thefo itowileg:"I Certify that in fhe performance of t,'1e work for w hich this permit is issued,I shall not employ any Berson <br /> in such mariPer as tc become subject to workman's comoepsation laws of California." <br /> contractors hieing or sub-contrasting signature certifies the following-, "lCertify treat in the perf9smance of fits work for which this permit is issued,!shall <br /> employ perSons subject to workman's compensation laws of California:' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul d reguliti ns of jhe_S@n Joaquin Local Health District. <br /> ' APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jwv 31 <br /> REMIT <br /> BASE EXPLANATION'S BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE !� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> B B 3 13 s 3 <br /> R ceived by IDate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETUAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ.ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �j <br />