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 hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) �U �? 5'rG G✓.�l - Address l`?-1 o <br /> a Owner Ai, P<5'-19 on Address 2-e�Z_.5- <br /> J:u <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. -V Emergency Telephone No. <br /> Contractor Licence No. — Z <br /> a Applicants Name (Print) 5- i ' --%�f � Title Date <br /> Please check Applicable Category (1-7) and Fill in the equired 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. 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 <br /> No o Chemical Toilets Stored <br /> 3. ERCOLATION_TJ;ST <br /> R. or R.C.E. Name ✓ c*~' L R.S. or R.C.E. No. GZ cI Z S� <br /> Test Location cr Cbyar- Test Date/Time -E-- U <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 <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/Amount/Mo. tv <br /> in g e manna as to br Of s rait9e su ssoigt w reri.rona fi*nom, owi jg:„5 r l*,fit hat in the performance of tAework for which thi.1 permit is issued,I shall not employ any person <br /> o ,. <br /> Contractor's hiring or sub-comractkVsignature cenitses Ow fuilovwng: I certify that in the performance of the work for which this permit is issued.I shall <br /> employ persons subject to workman's compensalron laws of California: <br /> I hereby certify that I have prepared this appy at' nand that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, les and reg at ns t San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X01 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ a <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE /CHECKED <br /> AMOUNT <br /> FEE 00 0 152 qrl <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> eceived by Date 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 />