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 is 4reby made to carry o_n�slness in the jurisdictional area of the San Joaquin Local Health.D'st 'ct <br /> H Business Name (DBA) X z7kj4 63��. Address - <br /> aOwner Address- v <br /> Firm Partners, Addresses and Telephone Numbers r ' <br /> CL <br /> Business Telephone No. -- Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title /L✓ f4 Date t <br /> Please check Applicable Category (1-7)and Fill in the Required InformationOa„s. x.,. 1,, t3 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. <br /> CAL. License No. CAL, License_Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address k` <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 $ x <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 /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 1 <br /> Job Address/Location f0 7Vig <br /> Own Address <br /> SEPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLArvf <br /> ❑ PERMANENT ❑ TEMPORARY_Q, ❑,NEW _._ © -REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-J e 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) ©' <br /> 6.w❑-PACKAGE TRE/1TMENT�OLANTYF-o y u , - lune 3o,,ig ---�---- �.-..--_ ._..,..., •,,.— <br /> Operator Name �'`=_ Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served ' <br /> 7. ❑ LAUNDRY For July 1,-June3V1;9 <br /> SIZE: ❑ Less Than 1,000 5q. Ft., ❑' dY T ari�1,000 Sc.-Pt. w�LS i <br /> ❑ DRY CLEANING, Chemicals Useid/"punt/Mo. t�• i_ <br /> hereby certify that 1'have prepared this application and th9t t`he work will be done-InQ.aceordaQce with San Joaquin County <br /> ordinances, state laws, and rules and regula ' sof San '3aquin:Local Health District. <br /> -APPLICANT'S SIGNATURE X J <br /> ' FOR DEPARTW T'JSE-OFIIL'Y - i; <br /> Fee Is Dile: ❑ ANNUALLY C1 PER UNIT_. ElPER SITE _ ❑ 8 <br /> _ ❑ EACHT__ January_1 Received B 1January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $�' REMIT <br /> BASE EXPLANATION DALE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS- v <br /> PRORATION - - <br /> PLUS <br /> ....PENALTY.... <br /> OTHER - - — <br /> Received by Date Receipt No, Permit No Is uance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE:,P.O.Sox 2009 STOCKTON'CA 11111 <br />