Laserfiche WebLink
Applications Will Be Processed When Submitted Properly compiewo <br /> oe <br /> ...y.. .. <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 /> Ad ress L11 -C C— <br /> Business N/�°me (DBA,x Owner ,� � � � xW <br /> Address <br /> a <br /> J Firm Partners, Addresses and Teleph ne Numbers Emergency Telephone No. <br /> a. Business Telephone No. <br /> a <br /> Contractor Licence No. Title Date <br /> Applicants Name (Print} ��'' p <br /> Please check Applicable Category (1-7) and Fill to the Required Information �^ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. _ CAL. License 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. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4.---[� SANITATION PERIT <br /> Job Addr s/Lo ation !` � (,� � <br /> Owners-© '�' "-A.?— Address <br /> 1C� LEACHING FI ❑ PACKAGE PLANT -� <br /> SEPTIC TANK ❑ CESSPOOL FIELD El SEEPAGE PIT❑ REPAIR 13 OTHER <br /> ❑ PERMANENT 11 TEMPORARY NEW �S <br /> g. ❑ 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 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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, <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wit n u f t <br /> ordinances, state laws, and les and regulations ofSa oaqui Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ER UNIT ❑ PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Receivedu y 31 <br /> FEE IS Due: ❑ ANNUALLY El PFR REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE 49 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER / 6/ <br /> Issuance Date Mailed Delivered <br /> eceived by Date Receipt No. permit . <br /> - 1601 E.HAZELT�N AVE <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> - ,P.O.ao,r 2609 STOCKTON,CA 9 <br />