Laserfiche WebLink
< APPLICATION <br /> (For Non-Translerehle, Rerucable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 055— Zov—U <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Heaith District _ <br /> Business Name(DBA) `Seo.yS AddressPCI 6-X-_l�SZ1 S'TTnQAl A) <br /> Owner M,4. F J�.aQI S.,,�/ - Address es <br /> Firm Partners. Addresses and Telephone Numbers — <br /> Business Telephone No Emergency Telephone No. <br /> Contractor Licence No. 3 — <br /> Applicants Name (Print) F l c)oo t7 Title 0ate /x �- <br /> Please check Applicable Category (1-7)and Fill In the Required Intorrnation <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.Liccse 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. of Chemical Toilets Stored _ <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R C.E No. (� <br /> Tes LOcatlon _- Test Date/Time tfi <br /> 4. SANITATION PERMIT br1E-sr X/AC 1 <br /> Job Address.Location�'7—fi�Or�'A/T2/J �� A m; A), o-Ir 9 lov/ <br /> i <br /> Owner -41.Q T-CN Address '?JJD A). t i5R__T 11W6,, -S7rCA;!'d- <br /> SEPTIC TANK ❑ CESSPOOL J� LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER rSui 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30. 19 <br /> Type Construction _ Disposal Site <br /> n <br /> No of Units Equipment Siorage/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 /> T. ❑ 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. I <br /> I <br /> a <br /> 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, and rules and regulatio he Sar Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE O EACH ❑ January 1 S Received By January 3. 0 JWy r d neceivea By July 31 <br /> REMIT <br /> BILLING RE�AI I I ANCE 5 <br /> EiASE EXPLANATION U AMOUN'D'UE CHECKED <br /> DATE DATE REMIT,F <br /> AMOUNT <br /> F E E <br /> USS <br /> PRORATION <br /> PLUS <br /> PCNAL i Y <br /> OTHER w # <br /> a•. <br /> QT F4EF1 <br /> HeceivrM by C'iete Ri![:eipt No Permd No Is ua ne¢ at> Maalyd nr•liv.re6 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES• 1601 E.HAZELTON AVE.,P.O.Bax 2009 ST O KTON,CA 95201 '•? 7 - <br />