Laserfiche WebLink
Applications Will Be Processed When Submitte rope <br /> rly <br /> APPLICATION SEpTAGE <br /> (For Non-Translerable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH.-PER <br /> � LIQUID WASTE <br /> -Ss in.the.jurisdic <br /> Application is hereby made to carry on busintion l area O IN San Joaquin Local Health District. <br /> mBusiness Name (DBA) Address <br /> i Owner _ _ - <br /> a _ <br /> JFirm Partners, Addresses and Telephone Numbers Emergency Telephone No; z <br /> aBusiness one No. - <br /> 1 Contractor Licence No. Title pate <br /> r— �.�_-� <br /> Applicants Name (Print) ;_k- <br /> Please <br /> �. <br /> 1 7 and FIII in the Required Information .-w <br /> Please check Applicable Category ( - 1 <br /> y, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 � Disposal Sites m <br /> For July 1, CAL. License Renewal No. <br /> Description(Make/Yr., Color) CAL. License No. <br /> Serial No. <br /> Capacity Gat.,Weights&Measures No. <br /> Equipment Parking Address ) ,� <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> i , <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test ocation <br /> 4, ANITATION PERMIT j ! <br /> x 'Job Address/Location-• Address 0 <br /> C Owner ❑ LEACHING FIELD 1:1 SEE PAGE PIT ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK C3 CESSPOOL. CHIEl f 1131REPAIR XOTHER �� LL� <br /> 13 PERMANENT ElTEMPORARY {l Y••� <br /> F 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 1pisposal Site , <br /> I Type Construction <br /> Equipment Storage/Cleaning Locations) <br /> No.of Units' n <br /> g, ❑ PACKAGE TREATMENT PLANT ' For July 1, -June 30, 19 Where Certified <br /> Operator Name - <br /> L <br /> Plant Location i No.Units Served <br /> Plant Capacity <br /> 7. 11 LAUNDRY-- For July i;-'June 30, 19 � <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ D Y CLEANING, Chemicals Used/Amount/Mo. <br /> gory �4 uo4o g rys{ t uviin "f.rertifY at in the performance of the work Iorwhichthis permit isissued,Ishall not employ any person <br /> ft SvCr h mannsr fQ tfflv9flW x%11 4 t€t u+r�ilzt� r a*°�n? ,ia' :itN+iat:^�of C.r i'l7nsl .' <br /> con4r wo . of i�esaoltr+fetitzp' l r t 6aes t�:r' following: "i coriify that the perlortnance_oI the work lot which this permit is issued,l shall <br /> employ pertxn5 tw0ftl Ilo- rlcmaxf s Cofnpensaopn lags of cdatirliia.• ; <br /> g <br /> I hereby certify that l h pre aced this app ication and th the work w' be done in accordance with San Joaquin County <br /> l -d-regul ns of the San aquin-Lo Hea District. <br /> Ordinances, state laws n A< <br /> APPLICANT'S SIGNATURE.X r -� <br /> FOR DEPARTMENT USE ONLY . <br /> ' ❑ January 1 &Received By.January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El REMITTANCE $ AMOUNT DUE CHECKED <br /> `BILLING REMITTED AMOUNT_. <br /> [ BASE EXPLANATION DATE DATE 06 <br /> FEE 0 <br /> LESS. ; <br /> PRORATION <br /> PLUS - •- - ti/ , <br /> 'PENALTY 'r <br /> OTHER - y <br /> OTHER <br /> 45, <br /> --g r <br /> reliv e <br /> µ ? nce Date Mailed <br /> Permi No. r°+�, IssuaCA 95201 <br /> TO Receipt No. <br /> Date - <br /> Received by f r. 1601 E.HAZELTON AVE.,P.O.Box 2008 STOGKTON, <br /> L-2 APPLICANT—RETURN ALL COPIES : <br /> ENVIRONMENTAL HEALTH PERMITlSERVICES <br /> I - - <br />