Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r APPLICATION t <br /> (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) 'e, 6,,z- Address <br /> z Owner Address j <br /> Firm Partners, Addresses and Telephone Numbers a <br /> aBusiness Telephone No: x3 "`r � Emergency Telephone Na. 1 <br /> Contractor Licence No. <br /> [ Applicants Name(Print) <br /> Title Date •= I <br /> Please check Applicable Category�Q_7) and Fill in the Required Information.,4 .. 9 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; June 30, 19—�- Disposal-Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. fi r <br /> Capacity Gal.,Weights & Measures No. <br /> fi <br /> Equipment Parking Address <br /> -2. ❑ PUMPER YARD <br /> ` For July 1, June 30, 19 <br /> No. of Vehicles Stored r <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 /> Test Location Test Date/Time O <br /> 4. F SANITATION PERMIT <br /> Job Address/Location 2 f G e� r�, - C-N L-4 ev 1: <br /> Owner G'Y!f9 Address S.a/l� 4' <br /> C9 SEPTIC TANK ❑ CESSPOOL ❑ -LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT {� <br /> IR PERMANENT ❑ TEMPORARY PS NEW ❑ REPAIR OTHER /Gi'�r &�� <br /> 5. ❑ CHEWICAL TOILETS For July 1,-June 30, 19 ,. <br /> i <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 <br /> Operator Name Where Certified <br /> f <br /> Plant Location , <br /> Plant Capacity No. Units Served 1person 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> '.Pomeowneror6oensedagent'ssignatureeertlfiesthcfotloling:1certifyyt`latintheperformance.oftheworl;forwhichthispermi',Is'sssued,Ishallnotempl <br /> In such manner as to become$LNecf to Workman's crmpemation iaws 01 1';1ilf0%,1ia" <br /> Contractor's luring or sub-contracting signatUM Carri4:Es the 0160WZily. "I Willy that in(he performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of California." <br /> 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, an rules and regulatio of the San Joaquin Local Health District. <br /> I , <br /> APPLICANT'S SIGNATURE X `'�� <br /> r a x <br /> t FOR DEPARTMENT.USE ONLY u. <br /> r s <br /> Fee Is Due: 13ANNUALLY ElPER UNIT ❑ PER SITE ❑ EACH _E3January 1 &Received By January 31 El July 1 &Received 6y July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> f LESS /1 <br /> 3 <br /> #' PRORATION Z, _ <br /> PLUS <br /> f PENALTY Z _ <br /> OTHER ' <br /> r , <br /> OTHER. _ <br /> 3l ��- ' 1111 ) � � <br /> Received by ate Receipt No. - Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />