Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE. <br /> Application i ereby madleno carry business'n the jurisdictional area of the Joa uin Local He Ith Di trict <br /> rn Business Name (DBA) Address ! <br /> a Owner Address ;. <br /> I <br /> J Firm Partners, Addresses and Tel p o e Num ers <br /> CL Business Telephone No. ( Emergency Telephone No. <br /> a �� r <br /> 1 Contractor Licence No. 7 <br /> 3 �6 <br /> Dale <br /> Title f - <br /> L Applicants Name (Print) ( I' <br /> Please check Applicable Category(1-7)and Fill the Required Information + I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _ 3 } <br /> For July 1, -' June 30, 19- Disposal Sites } <br /> Description(Make/Yr., Color) i+ <br /> .. T -r— - ---.�-- Y' CAL. License Renewal No.- _ <br /> Serial No. CAL. License No. t <br /> Capacity "'' ` ;Gal;,,,Weightsr& Measures No, r <br /> Equipment Parking Address- <br /> 2. <br /> ddress2. ❑ PUMPER YARD ti o . <br /> For July 1, June 30;-.19No. of Vehicles Stored <br /> « r 3 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name <br /> R.S. or R.C.E. No. -- <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT "�.I�/� -` iT <br /> Job Ad s/Local n <br /> Ad ress ' `" <br /> Owner ❑ PACKAGE PLANT <br /> 11 SEPTIC T NK 11 CESSPOOL 13 LEACHING FIELD SEEPAGE PITS r., <br /> PERMANENT ❑ TEMPORARY ❑ NEW OREPAIR ❑ OTHER <br /> 5. 13CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> E Type Construction Disposal Site <br /> No. of Units., Equipment Storage/Cleaning Location(s) <br /> 6. 1:1 PACKAGE TREATMENT PLANT Ea.r July 1, -June 30,.19.- <br /> t Where Certified + <br /> Operator Name <br /> Plant Location i <br /> Plant Capacity 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/Am6unt/Mo- <br /> ttQ'S}06Wrr+Sarptasc�� ct'cse�-^.�?'31r�te Kl?i3 h^Sai!cerirt lfertlf;'th tl^the per`ormance of theterk fort+;hieh tli+s permit is issued,l�lail not emptoy any-per,e'. <br /> ' �IYr,C, •n- ;il�lS +1 I1J�I1>lf iilV ' 1 shzM <br /> Contractors N!ing ar ssd•-CD0t!-,1Cri19 SIc n$ture certi'ic�s i'�e ;crt rlydlly: "i ;:er:i'ry Mat in the Nerf9rmarce of the work€er�Hhic41 this permit is issued, <br /> Ipersons subject to ww-kmans cGmpensatin,l laws Of Cuiiforilia." I <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 re ulation f the San,Joaquin Local Health District. <br /> t <br /> a <br /> APPLICANT'S SIGNATURE X <br /> t FOR DEPARTMENT USE ONLY _ <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> r .BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE D TE REMITTED AMOUNT <br /> 400S <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> It .j <br /> OTHER L , <br /> OTHER <br /> ' Received by Da[e; -` -4.,,Receipt No- i s Permit No, Issua ce Date Mal ed Delivered <br /> :.. <br /> 201 <br /> APPLICANT—RETURN ALL coAtsTo: ENVIRONMENTAL'HEALTH PERMIT/SERVICES 1601 E.-HAZELTON AVE,,P.O.Box 2909 STOCKTON.CA 95 <br /> 4..f <br />