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 /> Applicata �hereby made to carry onliasiness in thejuuuU ' dictional area of theLan Joaqui Cal a Distric <br /> H Business Name (DBA) :_� �lE �'1�,Sj" Address <br /> - <br /> z Owner Address <br /> Firm Partners,Addresses and le hone Numbers <br /> aBusiness Telephone No. 'S5iZ Emergency Telephone No._ <br /> Contractor Licence No. <br /> Applicants Name(Print)_WAAIE4i Title Dat 4r/I <br /> Please check Applicable Cat ) q � <br /> pp 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/ G-blow' `, a <br /> Serial No. CAL. License No. CAL.Licensecpdal'No. <br /> Capacity Gal., Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD _ <br /> k, h1 <br /> ��Y `. <br /> For July 1, Junm„19 <br /> No.of Vehicles Stored <br /> r <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 /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT :, N <br /> Job Addre s/ oc tiori 7� _, TJY /Cr1 1 j <br /> Owner ► r; f Address <br /> r�OCPTIC TANK 1:1 CESSPOOL 2"CEACHING FIECR. 13�'E E AGOIT -,04PACK.AGE-PLANT <br /> d-f-ERMANENT ❑ TEMPORARY Q-1GEW '❑,,REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,.;June 30, 19 R <br /> Type Construction Disposal Site i �I <br /> No. of Units E uio I <br /> q ptreni$torage/Cleariing Lor ti <br /> 6. ❑ PACKAGE TREATMENT PLANT For Jul 1,?�vne 30, 19^- t: <br /> Operator Name '°� Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19______L___ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hsuchmanneras ensad+genYsslttowor aan,s sthefoilwrinp:"lcetiily#Iyth�tReperfarm;rtcepfifk>+erkfxwf>icAtlt3 errititisissued,lsitdlinote <br /> in such manner as to become sirtgect to vrorkmasf's.compem ' n taws of ca TprniA � mpWany port <br /> employ persotw'sns s sub.7 os ,r,,,ontncting AlDrWrtwe r <br /> employ psrsens sutrlect to workman's compensation Iii o iivmia' !c>fflity PiliftMr10 of IN ii►ork for which this permit is issued,f shah <br /> .I hereby certify that I have pr a his application an work will be done iR accordance with San Joaquin County C <br /> ordinances,state laws,and r d regulations of n Jo tai c ealth District. Qi <br /> APPLICANT'S SIGNATURE <br /> FOR,tEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑',EAC H ❑ January 1&Received By January 31 ❑July i&Received By July 31 <br /> ' REMIT <br /> BASE EXPLANATION BILLING ;REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r � <br /> FEE S g <br /> LESS + . AyLie <br /> PRORATION : <br /> .PLUS <br /> PENALTY Z/ <br /> OTHER i <br /> OTHER f <br /> q77Z� WS_��Received by Date Receipt No. Permit No. Issu nce a Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON _, .O.Box 2009 STOCKTON,CA 95201 <br />