Laserfiche WebLink
Property .PHvn. <br /> Applications Will Be Processed When Submitted teLICACompleted.Be Sure o l <br /> gIII <br /> .. .,- <br /> r (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQulo WASTE <br /> Application i ereby ma a to carry n bsiness in th jurisdictional area of the San Joaquin��a ealtfj D�rict f <br /> 0, r �( Address <br /> IF Business Name (D ) Address <br /> aOwner <br /> Firm Partners, Addresses and Telephone`ne Numbers Emergency Telephone No. q4 <br /> aBusiness Telephone No. Z Z G <br /> Contractor Licence No. Date �n <br /> �Intolm�Stlll Title <br /> Applicants Name {Print)Please check Applicable Category (1-7)and Fill In the Require <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. IL CAL..License No. <br /> Capacity _.' 'Gal.'Weights'&Measures No. <br /> Equipment Parking Address ' <br /> k 2. ❑ PUMPER YARD f s <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. <br /> R.S. or R.C.E. NameTest Date/Time <br /> TesVSCANITATION <br /> ation r <br /> 4. PERMIT � � e% . <br /> Job Addres cation a <br /> �^- Address <br /> OoJ r ❑ PACKAGE PLANT <br /> 1 ❑ CESSPOOL EACHING FIELD SEEPAGE PIT ❑ OTHER <br /> EPTIC TAN '❑ REPAIR <br /> L't PERMANENT ❑ TEMPORARY u NEW <br /> } 5. 13CHEMICAL TOILETS For..Julyir-June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT-PLANT,For-July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> Na. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 11Less Than 1,000 Sq. Ft., El More Than r1,000 Sq. Ft. <br /> 13 DRY CLEANING, Chemicals Used/Amount/Mo ... ! 0 <br /> � r -� <br /> !1 <br /> j I hereby certify that I have prepared this application and that the work will be done i accordance with San Joaquin County <br /> ordinances, state laws, and r s and regulations of the San Joaquin Local Heal h District. <br /> APPLICANT'S SIGNATURE X <br /> 1 "w FOR DEPARTMENT U - yO�NLY <br /> r ❑ PER SITE ❑ EACH 13 January uary 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT p REMIT <br /> BILLING R i4T7ANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE Ij DATE REMITTED f AMOUNT <br /> FEE <br /> LESS, (, ; <br /> k PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f <br /> OTHER ,? S <br /> Receipt No. <br /> Permit No. I uance D to Mailed Delivered <br /> Date <br /> Received 6y 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITlSERYICES <br />