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 isA hereby made to car,on business in the jurisdictional area of the San Joaquin Local Health District <br /> ��_ <br /> 1A F Business Name (DBA)D, �ep <br /> -�� ��QMAXAddress �� ) `? , <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No_ Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) T-,0.1�1 __.. `SIli-AS Title r✓ Date <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 3O, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> .Serial No. ' CAL. License No. CAL. License Renewal"No. <br /> '.Capacity 4 Gal.,Weights & Measuees_No. <br /> LgrEquipment Parking Address s ! # <br /> 1. ❑ PUMPER YARD <br /> For July 1, 1 June 30, 19 t <br /> O No. of Vehicles Stored 1 *4 # <br /> No. of Chemical Toilets Stored 7 4 <br /> 3. ❑"PERCOLATION TEST <br /> R.S. "_R.C.E. Name t R.S. or R.C.E. No. 4 <br /> Test Location if r- Test Date/Time i <br /> 4. I�.oc�SANITATION PERMIT° {fi {, ' <br /> Job Address/Location Z _ e AJ <br /> ' <br /> Owner Address ❑ PACKAGE PLANT <br /> Gam <br /> ISEPTIC TANK 11 CESSPOOL �LEACHIN,G FIELD' 11 SEEPAGE PIT <br /> 14 ''rERMANENT ❑ TEMPORARY ❑ REPAIR ❑ OTHER <br /> 5: -CHEMICAL TOILETS 'For July,1,-June 30, 19 } <br /> Type Construction ( Disposal Site :• r' <br /> No. of Units _ Equiprient!Storage/Cleaning Location(s) F <br /> 6. ❑ PACKAGt TREATMENT PLANT_ For July 1,;June 30, 19 t <br /> operator.Name ` Where Certified f ' <br /> Plant Location ) " } ' ' f r <br /> Planf Capacity -� �� No:Units Served I <br /> 7. ❑rLAUNDRY For July 1, -Juner30, 19 <br /> SIZE: - ❑ LesstThan 1,000 Sq'Ft j ❑ More Than 1,000 Sq. Ft� <br /> ❑ DRY CLEANING, Chemicals Used/AmouiiVMo.­` <br /> i j. ra I hereby certify that I e prepared this applicatio nd that the wo k will be done inaccordancewith San Joaquin County ) <br /> o►dinances, state law' an re ations San uin Lo al Health District.,% <br /> APPLICANT'S SIGNATURE X./-'-,-- <br /> f <br /> $. } <br /> FOR DEPARTMENT USE ONLY <br /> e 'c rFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> $ I <br /> BASE EXPLANATION _ AMOUNT DUE CHECKED <br /> ¢ DATE DATE REMITTED. AMOUNT I <br /> FEE,- t. 4S '9 1 <br /> c <br /> LESS rte' -. ► <br /> PRORATION + 11 <br /> PLUS <br /> PENALTY <br /> F <br /> OTHER i E <br /> OTHER <br /> Received by Date Receipt No. Permit No. .u."ad Dath Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />