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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE I <br /> LIQUID WASTE <br /> Ap7plicatio r�ereb ade to car on usiness in a urisdictional area of the S$n �quinl�al Health District <br /> y, N Business Name (DBA) CARGATe,S . go ) Address /� FSurroAJ Ak <br /> z Owner. ern CC;r/e Address <br /> I J Firm Partners, Addresses and Telephone Numbers _ <br /> Business Telephone No. 'r 3 G`Sgy - Emergency Telephone No. 1 <br /> Contractor Licence No. <br /> L Applicants Name (Print) ( Title Date t <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 '""# Disposal Sites I <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licz,se Renewal No. -it <br /> t <br /> Capacity Gal., Weights &Measures No. <br /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, 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. �) <br /> I Test Location Test Date/Tillie _ T X <br /> l <br /> 4. ❑ SANITATION PERMAT,, w <br /> Job AddresW ovation '1s9? 5' UrUI o ru �Z0AO J ; <br /> O ner Oe- A N Address <br /> WSEPTIC TANK ❑ CESSPOOL ErLEACHING FIELD- ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY IT NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ 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 U <br /> Where Certified <br /> Operator Name S <br /> Plant Location ' <br /> Na. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br />{ SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> k ❑ DRY CLEANING, Chemicals Used/Amount/Mo.. <br /> f <br /> f <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 and regulations of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> F - <br /> - FOR DEPARTMENT USE ONLY <br /> - ❑ PER SITE ❑ EACH El 1 8 Received By January 31 July 1 &Received By July 31 <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT <br /> : REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNTDUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> FEE t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER z <br /> OTHERAll <br /> - <br /> ,_ <br /> ' R by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> i . . PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.'O.Box 2009 STOCKTON,CA 95201 <br />