Laserfiche WebLink
-�. .� <br /> Applications Will Be Processed When Submitted Properly Completed. Be SureTobign IneAppimativil. 1 <br /> _ APPLICATION <br /> ' (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on busine in the j h ictional area of th Sail Joa quino 1 Health District t <br /> E Business Name (DBA) Address j <br /> i Owner L r7-E:, NNINO�NA Address <br /> a <br /> J Firm Partners, Addresses�and , on Numbers Emergency Telephone No, <br /> a Business Telephone No. d L)=" :�Contractor Licence No. `1 , ' ate <br /> A°pplicants Name _ I <br /> a Print <br /> (` kN r) <br /> T ,.L • ) • � , <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> f 1" ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30;:.19 - - <br /> Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No.' <br /> Serial No. CAL. License No. <br /> 'Capacity-_:!"----....e Gal.;Weights &Measures-No.- <br /> Equipment <br /> No:Equipment Parking Address r <br /> 2. ❑ PUMPER YARD q <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> - -r-- <br /> No. Chemical Toilets—S-to— <br /> ofred <br /> -3.,0 PERCOLATION TEST i <br /> ! R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name <br /> TTest Date/Time <br /> Test Location <br /> 7, <br /> 4. ❑ SANITATION PER I4 T� + . <br /> Job Ad ess/Location <br /> Owner Addres <br /> _SEEPAGE PIT.. ❑-PACKAGE_P.LAN7 Q) <br /> ❑ SEPTIC TANK 1:1 CESSPOOL( ❑;LEACHING FIELDf ❑ OTHER {7; <br />` <br /> ❑ PERMANENT 11 TEMPORARY ❑ NEW REPAIR> =7 <br /> 5. 11 CHEMICAL TOILETS For.July i,-June 30, 19 <br /> t � Disposal Site <br /> Type Construction _j - - - <br /> j <br /> 'No. of Units j Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified I <br /> t Operator Name I <br /> Plant Location <br /> # No. Units Served <br /> Plant Capacity f <br /> I 4 <br /> 7, ❑ LAUNDRY For July 1, lune 30, 19 <br /> ❑ Less Than 1,000 S Ft.,. ❑ More..Than1, <br /> ` ,000 Sq. Ft. I <br /> SIZE: q: j a <br /> e ❑ DRY CLEANING, Chemicals Used/Amount/MON <br /> I l Foameownerortieenaedagerx'ssisnc:urecartifisrthes.togowi::g:"lrcriifytha,tinthe_pe;form2nceGf:hews.rrivrllhi1, t?:ispermitisissuef isjailnotelnp?e;anyp - of <br /> in such manner as to become subject to workman j c6mpaltsatfeit laws off,,lif�E:kiil." <br /> Contractor's Uireng or sub-contracting sign8ture certifies t'kc fotlowinj: `i certify that in III,perfurwa nce of the work for which thi�'permit is isst e�,I shalj_ <br /> employ persons subject to workman's compensattnsl laws,of California."- <br /> a , <br /> * ! <br /> I hereby c if that I'have prepared thi application and that the work will be done in-accordancd with San Joaquin County <br /> ordinanc ate nd rule and regu atio oft San J�oaqun'Local Health Djistrict. � <br /> ' •-y7 _. <br /> APPLICANT'S SIGNATUR # <br /> t # <br /> FOR DEPARTMENT USE ONLY <br /> ' ❑ PER <br /> UNIT' 13 PER SITE EI EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received H MITuly 31 <br /> Fee Is Dile: ❑ ANNUALLY <br /> T _ BILLING REMITTANCE I $ t.�. AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE -DATE-, ' 'REMITTED: t „y r r`�� i ''f AMOUNT <br /> l {} e <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1F <br /> OTHER 1: <br /> [A 11 I <br /> Issuance Date Mailed Delivered <br /> Receipt No- Permit No - <br /> eceived by Date . 17601 E.HAZELTDN-AVE.,P.O.f3a■2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> k + - <br />