Laserfiche WebLink
ApplicationsWill 8e Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 71 (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE SCC <br /> r Appl ication is hereby made to carry on busines In the JI'sscli tional area oft S Jo�p uin Lq�i e h I trio <br /> ,, Business Name (DBA) ''PIliftT Septic Taxlk ;O• S � J3AR (nV a ~C <br /> Ernest Roberge ' Address O , Calif. 95240 <br /> 1Owner Address Sam! <br /> J Firm Partners, Addresses and lephone Numbers <br /> aBusiness Telephone No. 36 -51©5 <br /> 4 Emergency Telephone No. <br /> -,Contractor Licence No. 32 <br /> L Applicants Name (Print) lRoberge Title @ d <br /> Please check Applicable Category Date <br /> g ry{i-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 I. 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. W <br /> Test Location Test Date/Time <br /> 4. IN SANITATION PERMIT • ;.. �.{ <br /> Job Address/Location Skinner Ranch 13115 N. Hiwy 99 Lodi, Calif. 4524© <br /> Owner <br /> ❑ SEPTIC TANK 11 CESSPOOL LEACHING FIELD Address <br /> SEEPAGE PIT ❑ PACKAGE PLANT <br /> CKPERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS -For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity <br /> 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 /> I hereby certify that I have prepared this application and that the work will be done in ]2rce'with San'Joaquin County <br /> ordinances, state laws, a rules and regMp <br /> s of the San Joaquinloc I He It District <br /> APPLICANT'S SIGNATURE X 4 *. <br /> t <br /> FOR DEPARTMENT USE ONLY _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ Januar ceived By January 31 ❑ July 1 &'Heceived By July 31 <br /> BASE EXPLANATION BILLING REMITTA .' REMIT <br /> DATE ATE REMITTED <br /> AMOUNT DUE I CHECKED <br /> FEE _ AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date ceipt No. Permit No. Issuance Date Mailed ellvere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMrusERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 9 01 <br />