Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Cornpleted. Be SureTo <br /> APPLICATION <br /> (For Non-Transferablei-Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District .- <br /> I-Business Name(DBA) F� 7v <br /> esr, Address t� E�/yJ,sF/f <br /> Address - <br /> a Owner <br /> 0 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. <br /> 1 Contractor Licence No. _ <br /> Title �� � Date <br /> L Applicants Name (Print) a `JOd T x <br /> Please check Applicable Category (1-7)and Fill in the Required Intormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) + <br /> For July 1, _ June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal-No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD a ' <br /> For July 1, June 30, 19 { <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. z <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location - <br /> 4. 0( SANITATION PERMIT�t'S ®� <br /> Job Address/Location <br /> Owner7-R 12 <br /> Address <br /> SE'PIT TA1�iK ❑ ❑ PACKAGE PLANT' <br /> CESSPOOL LEACHING FIELD 113 SEEPAGE PIT OTHER <br /> PERMANENT TEMPORARY NEW REPAIR <br /> 5. ❑ CHEM16AL:TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> + No. of Units Equipment Storage/Cleaning Location(s) •01 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 in <br /> h � . Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY • For July 1, -June,30,.19 ... w <br /> SIZE: '- ❑.Less^Tha -" .,600 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> _• r <br /> j ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home ownarurlicensed ag^-nt'are•`•dl'severtotmartcpoltbewwkfcruflirhthispernitisi llnrtrr:pioy3ny p:n <br /> In such manocr as to became subiec'iO ? <br /> 1. riQrltraClOr 5 hiring a► &tt'�•.,.n-retr.,,� .;�... .::a '.:.6:. -c; :, s�..ow.ug. i ce;liiy tIl3i lig i1,2 p�rfG�inanGe Cf.hi;V:Crk{Or',Nc;�Ei ���1"t .51554!.�,i Sli2j, <br /> employ persons subject to Wt;lAmatia co�rai psi ii lu:ia v.Lii'iW liu." t } r <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 rules and regulations San Joaquin LocalHealthDistr' <br /> APPLICANT'S SIGNATURE X <br /> Fee <br /> -`FORDEPARTMENT.USE NLY e: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ Jdhuary 1 &Received By'January 31 E] July 1 &ReceijeR�E6MylTuiy 31 <br /> BASE .EXPLANATION BILLING +REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE - DATE A- REMITTED=- AMOUNT <br /> FEE <br /> C LESS a r <br /> PRORATION <br /> PLUS .w - pi ( — 1 - Cr .3 Q - <br /> PENALTY <br /> - <br /> . OTHER - r' • <br /> OTHER <br /> Received-by <br /> ` Date Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E:HA2ELTON AVE.,P,O.Box 2009 STOCKTON,CA 85201 <br />