Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Zt�C D U,V+► APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE I� <br /> Z S- 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 /> F Business Name (DBA) AA43 1SJ1v 94/ 5.7L. Address 77W L. 1144 Lr7Sf <br /> aOwner.4ed�i2 W 40*c. Address /Fob T216,,76 .20 . 5.u1rE <br /> u Firm Partners, Addresses{ d T le hone Numbers <br /> aBusiness Telephone No.C��1 f�N'72 —/yyi Emergency Telephone No.C9/` 9z '924 <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) Title Date �Z <br /> Please check Applicable Category (1-7) and Fill in the Required 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. El PUMPER YARD Av�For July 1, June 30, 19 1 I <br /> No. of Vehicles Stored I II <br /> No. of Chemical Toilets Stored <br /> 3. 32L PERCOLATION TEST <br /> R.S. or R.C.E. Name I1/E�L p, �Q.�pyr'2 5'p�/ R.S. or R.C.E. No. /eCF yy�/ �J <br /> Test Location -4EC�2^'L`� '* All'- Test Date/Time ne,-% .4`: 4ae- Co i 99y <br /> 4. ❑ SANITATION PERMIT ��� �Tl�cflFn SH`T <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. <br /> Homeowner or licensed agent's signataurs oertMesthe foilowing:1 Gerfify that in the performance of the work for which this permit is issued.I shall not em ploy any person <br /> in such manner as to become subjectto woa:man's compensation laws of California.' <br /> Contractor's hiring or sub-contracting signatwn certities the following: 1 certify that in the performance of the work for which this permit is issued,I stlatl <br /> employ persons subject to workman's compensation taws of Cahtornia, <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an ul s and r Mations Of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X e 4 q/ <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> / AM�OU`NT C� <br /> FEE Io(o-9'Z Z L� IZ� � L� ��� kfJ 3 `r L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receive y 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.Boz 2009 STOCKTON,CA 95201 <br />