Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure' o Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEAL' H�PERMIT <br /> LIQUID WASTE l <br /> Applicati hereby m de to cam'on busies in the jurisdictional area of t San aquin.Local Health District.__ <br /> F Business Name (DBA)' R t -�zs'Cfs lrie. Address •��� �O '. ,T_Z_LO/ <br /> z Ownerdt . Address <br /> J Firm Partners, Addresses and Te/�p one N tiers _ l <br /> a. Business Telephone No. �"� ".�t Emergency Telephone No.- <br /> .,. ..... <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) rE Title l T Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> I. ElPUMPER 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. <br /> Capacity Gal.,Weights &Measures No. ' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored T <br /> No. of Chemical Toilets Stored f <br />` 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Te st cation Test Date/Time <br /> 4.^SANITATION PERMI <br /> Job Addr s Locatio LI jvj> N <br /> O ner Addr ssv � .. ��vJJJ <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT '�❑-PACKAGE PLANT _ <br /> PERMANENT ❑ TEMPORARY ❑ NEW i ❑ REPAIR ❑ ;OTHER j <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 � i <br /> Type Construction Disposal Site - <br /> --- - �. <br /> No. of Units E ui ment Stora e/Cleanin -Location(s) < �' I <br /> q p. g 9 _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I `=' "f; Where Certified t <br /> Plant Location <br /> Plant Capacity _ i No. UK-its Served I <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19- w <br /> SIZE: ❑ Less Than 1,000 Sq. Ft,. ❑ More Than 1,000 Sq. Ft. tl R r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ` <br /> � t <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with;San Joaquin County- q <br /> ordinances, state laws, and les and re atio of the oaquin Local Health District. �m <br /> - <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> 3... L 'I <br /> Fee Is Due: ❑ ANNUALLY , ❑ PER UNIT ❑ PER SITE i ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> f.BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED } <br /> DATE -- DATE RE EDov_ Iff AMOUNT <br /> FEE 46/ I � . .. { _.. . ( [, d� <br /> 1 <br /> ot <br /> i <br /> _ LESS ! <br /> PRORATION' '-• I - (- ...a� - - - <br /> PLUS <br /> PENALTY 'b• - - _ - <br /> OTHER I <br /> OTHEn - <br /> �- ri <br /> Received'by Date - Receipt No. Permit No, - Iss nce to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.H.A. N AVE.-P.O.Box 2009 STOCKTON,GA 95201 <br />