Laserfiche WebLink
w !w / G/ `7 <br /> "Applications Will Be Processed When Submitted Properdy'Corlilp e ee -. <br /> APPLICATION <br /> (For Non-Transferable;Revocable,and 5uspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE Y <br /> ti►a'tem <br /> g�201 <br /> Application is hereby made to carry on business in thJurisdictional area of the San Joaquin local Health District, <br /> Address <br /> HBusiness Name (DBA)Dr Address <br /> aOwner �r <br /> u Firm Partners, Addresses and Telephone Numbers Emergency Telephone No.. <br /> IL Business Telephone No. DIX " <br /> IL <br /> Contractor Licence No. I Title _ Date <br /> L Applicants Name (Print) r <br /> Please check Applicable Category,1-7)and Fill in the Required Information:. tt <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 4 - Disposal Sites <br /> M <br /> Description(Make/Yr., Color) ICAL. License Renewal No. <br /> Serial No. I�, CAL. License No. <br /> ��. Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address �N <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored 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 jr Test Date/Time <br /> TestL cation <br /> r 4. SANITATION PERMIT <br /> Job Address/Location A91Zi. L b. <br /> ,tee.-. I�_ Lr•,/ Address <br /> O ner - LEACHING ❑ GE PIT ❑ PACKAGE PLANT <br /> ❑ G FIELD SEEPAGE "- <br /> SEPTIC TANK ❑ CESSPOOL ❑ OTHER ` <br /> aq ❑ NEW REPAIR <br /> PERMANENT ❑ TEMPORARY z <br /> 5. ❑ CHEMICAL TOILETS Fo`July 1, -June 30, 19 <br /> Type Construction <br /> II Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br /> �l <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> ' Plant Location I' <br /> No. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1, -��June 30�9More Than 1,000 Sq. Ft T £ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., b: <br /> ❑ DRY CLEANING,Chemicals rsed/Amount/Mo. <br /> nrSiS 1?:- ' ?. ,c r•i1.c.or';:cr;; lc t Is terms Is ito; s <br /> Home owner orllcnnaodn9ent'SrigrtAturdGflrtlfEsa tI�A46llnv+lnn '; 5' n r i i torwhiehthis permit i5 issued,I shall <br /> in SUCK manner alio becarrll?Isubject to workmali s camp?Its�tlrl�la r: c Calii =i�'{ V y . <br /> Contractor's hiring or suh•GontrB Ging si5rrature cnr.l *.F.: i"r. <br /> employ persons suboct to wlbrkman's eompensatiail IkS.s of <br /> I hereby certify that,l hay prepared this application and that the work'11H <br /> ill done in accordance with San Joaquin County <br /> ordinances, state lav , and regul ns of the S oaquiL <br /> n o Hea h District. <br /> APPLICANT'S SIGNATURE <br /> . fl <br /> I <br /> ! I <br /> FOR DEPARTMENT USE ONLY - <br /> ❑ ❑ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedByJuly 31 <br /> Fee Is Due: ANNUALLY PER UNIT <br /> MIT <br /> 'I�: BILLING REMITTANCE $ AMOUNT DUE' CHECKED <br /> -BASE EXPLANATION DATE DATE .REMITTED AMOUNT <br /> FEE { — <br /> LESS ill e <br /> ' PRORATION <br /> PLUS <br /> PENALTY �- <br /> EII ti s <br /> OTHER J t_ <br /> OTHER <br /> Is nce ate Mailed .Delivered <br /> Date Rec t N Permit No. <br /> Received by 1601 E. AZELTON AVE.',P.O.Boni 2009 STOCKTON,CA 9520 <br /> APPLICANT—RETURN�ALL11COPIES TO: IRO_ ENT HEALTH PERMIT/SERVICES <br /> a IQIII �` <br />