Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. Be SureTo51gn ineJ%ppucanun <br /> APPLICATION / <br /> (For Non-Transferable, Revocable, and Suspendable) / SEPTAGE <br /> '. ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 07-l3usiness a (DBA �Afddress <br /> a Owner <br /> I( <br /> V� 5 Address Q <br /> J Firm Partners, Addresses and Telephone Numbers <br /> d Emergency Telephone No. <br /> CL Business Telephone No. <br /> Q <br /> Contractor Licence No. <br /> � <br /> Applicants Name (Print) Title Date ti <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. I CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address s <br /> 2. ❑ PUMPER YARD � �} <br /> For July 1, IJune 30,-19 T <br /> No. of Vehicles Stored 1 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST _J <br /> N- ' R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time . <br /> 4. MSANITATION PERMIT <br /> w 'b <br /> Job Address/Location �p S <br /> Owner Ll re y 5 7 1,11 i Address Mo 6 #~` � <br /> -9 SEPTIC TANK ❑ CESSPOOL � FI <br /> LEACHING ELD 11SEEPAGE PIT*r ❑ PACKAGE PLANT <br /> PERMANENT © TEMPORARY 4NEW ❑•REPAIR ❑ OTHER 4 <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 --C <br /> Operator Name Where Certified <br /> Plant Location ' <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,-Chemicals Used/Arrount/Mo. <br /> Homeownerorlicensedagom'e signature eArtrunesthefotlowing:"I certify that In the performance of Lheworkfcrwhich thispermit is issued,I shall not employ any person <br /> in such manner as to become subiect to`rior'rnian cr,tl4ensat cc=ars of California." <br /> Contractor's hiring or sub-ce.-AMC ng 1VIV31L;F8 cert--;'is 1'<a b7!kow:ng: "i ccrf„-y that in the performance of the woi k for which this permit is issued,I sfitall <br /> employ persons subject to work an's compcnsat:on laws of Cai;,c ria" <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, d ules a eg ion o he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: E3 ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE TANCE $ AMOUNT DUE CHECKED <br /> - DATE TE REMITTED AMOUNT <br /> �^ �o. <br /> FEE <br /> LESS Y J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> 1 �f fl ��3-S�- o <br /> Received by Date Receipt No. Permit Nu. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRO"ENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 009 STOCKTON,CA 95201 <br /> /0" of L ea c-lL r YiA W CL Iye- 10,E M 1, Il er <br />