Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> y APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 3 <br /> LIQUID WASTE A... <br /> Application is eb made to car�n business in the jurisdictional area of the San Joaquin Local Health.District/l <br /> F Business Name ( BA) �O I rtC` d��s M Address <br /> a Owner D (d1 ! : �/R?. Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephone No. �. c "GlZ, : ` Emergency Telephone.No. <br /> Contractor Licence No. <br /> Applicants Name {Print) Title - �� Date46 <br /> 4f .. <br /> Please check Applicable Category(1-7)and Fill in the Required Information ,... <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) off' <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. ❑ PUMPERYARD I i <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored {) <br /> 3. ❑ PERCOLATION TEST v <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑4SANITATION PERMIT � <br /> Job Address/Lo tion �� ^-�' ✓e�6�C vQ/4 (�, <br /> Owner" Address f m �'{I <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ,SEEPAGE PIT .❑ PACKAGE PLANT f l <br /> ❑ PERMANENT E] TEMPORARY El NEW OREPAIR ❑ OTHER \ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,.19 <br /> Type Construction L Disposal Site -^ - <br /> No. of Units Equipment Storage/Cleaning'Location(s) ._ . <br /> 6. ❑ PACKAGE TREATMENT PLANT Far July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity ' No. Units Served - <br /> 7. ❑ LAUNDRY For Jul 1,'-June 30,19- T I. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,-,-. ❑ More Than 1,000 Sq. Ft. <br /> ❑ <br /> �. <br /> DRY CLEANING,Chemicals Used%Amount/Mo. ➢� <br /> t�cnl�o:rr�rnrHcatlsvdnyant'sa;gna'nl arsr�°�F�erf�et��ln�ln�:"IrtifythatinMeperforminceoftheworkforwhichthispermitisissued,tshaNnotemployanyperson <br /> 41 rn or -vs•t:::-±;3Gi: ,r:a:,:�c r .t'rrr -: 3�I:oer.ng: `I ceriify that in the performance of the work for which thz pe,rhit is issued,t shall <br /> er"Ofoy petro s su*ct coni'pensa'.i n raw,of fialitornia: <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, an/r,� and rjulation of the San Joaquin Local Health District. a tr <br /> _ r. <br /> APPLICANT'S SIGNATURE X <br /> .ig& <br /> ' t FOR DEPARTMENT USE ONLY. f t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July-31 <br /> REMIT <br /> n y BASE EXPLANATION BILLING REMITTANCE . $ AMOUNT DUE CHECKED <br /> DATE r /_ IDA REMITTED. 7 AMOUNT <br /> FEE'i <br /> PRORATION - - - <br /> PLUS -''" ' <br /> . PENALTY �"t �..(.. <br /> OTHER <br /> _ OTHER <br /> Received by Date t Receipt No. Permit No Issfiance pate Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: EN{rVIRONMENTAL"HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br /> gnz <br /> i` 7 <br />