Laserfiche WebLink
tit Applications Will Be Processed When Submitted Properly Completedliesure 10 W9" rr�►rr ��" ' <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and 5uspendable) SEPTAGE _ <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE A <br /> ` Application is hereby made to carry on bus ess in the jurisdictional area of the Sa Joaquin Local Health District <br /> Business Name (DBA) ��� Address 4' <br /> z <br /> Address <br /> Owner <br /> 4 <br /> a Firm Partners, Addresses and Tele h nem Numbers Emergency Telephone No. <br /> 3. Business Telephone No. <br /> Contractor Licence No. ' Date <br /> Title <br /> I-Applicants Name (Print) CLPR1PIGE'S SEPTIC & SE'�u'ER.SERVICE , <br /> Please check Applicable Category (1-7)and Fill in the Required Information 263 Se. G,o Si!� �;c G21!f. 95205 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) CCII tcra , h <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. u <br /> Capacity " ' Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD - s <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.G.E. No. <br /> R.S. or R.C.E. Name t w Test Date/Tlme <br /> Test Location G�a C? ,fj� C. <br /> 4. 11 SANITATION PERMIT `f, /1, # f d ,�j J+' G� <br /> Job Address/ ca ion <br /> � <br /> Address <br /> Owner <br /> ,�SEEPAGE PIT ❑ PACKAGE PLANT <br /> SEPTIC TANK 11 CESSPOOL _ LEACHING FIELDµ ❑ REPAIR ❑ OTHER <br /> PERMANENT 11TEMPORARY ;� NEW _� ]d <br /> g, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 • <br /> Disposal Site <br /> Type Construction - <br /> No. of Units Equipment Storage/Cieaning Location(s) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location x No. Units Served <br /> Plant Capacity <br /> 1 <br /> For Jul 1 <br /> 7. 11 LAUNDRY Y , June-Ju 30, 19❑ More Than 1,400 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ,. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo, ti » <br /> � t <br /> he work will be done in accordance with San Joaquin County <br /> 1 hereby certify that I have prepared this application and that t <br /> ordinances, state laws, an rule nd regulations of the San Joaquin Local Health District. <br /> 4 <br /> APPLICANT'S SIGNATURE X 253 Sc. 01m Stoo-:(G'1, Calif. 95205 <br /> Ph.463-3%,;9Cei:�rac;cr's Lig {.267177� <br /> FOR DEPARTMENT USE ONLY <br /> " PER UNIT �( PER SITE ❑'ERCH ❑ January 1 &Received By January 31 © July 1 8.Received 8y July 31 <br /> Fee is Due: ❑ ANNUALLY :. ❑ Fs REMIT <br /> } BILLING - REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE { DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION i T <br /> PLUS '+ <br /> PENALTY <br /> OTHER <br /> r <br /> P <br /> OTHER <br /> Permit No. Issuance Date Mailed Del' ered <br /> Received by ate._ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br /> APPLICANT—RETURN ALL COPesTO: ENVIRONMENT�A�L,HEALTH PERMITISEAYICES <br />