Laserfiche WebLink
A 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 M5—a9_4(p <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) Address <br /> a Owner TOM RRnw-W __ AddressMAftrECA- CA. 9'5334, <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) WAi_-71-EQ F_- GURTLM Title CtViL F_AG1Nr-_M Date 89 <br /> Please check Applicable Category (1-7) and Fill in the Required Information 4'1e I` ^TTT HEW PLPtZ^ PNO1�iE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) LObt; GRL>t-0RR1 At 95240 (209)368-4ts9 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. - CAt, License.No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. _ <br /> Equipment Parking Address <br /> 2. Q PUMPER YARD <br /> For July 1, June 30, 19 _ <br /> Noz;- Vehicles Stored <br /> No'IRf Chemical Toilets Stored _ - <br /> 3. Q PERCOLATION TEST f-Ao 1•t' (2�*) A-1S9 \Iy1S^ 8�— <br /> R.S. or R.C.E. Name WIA►z� E C U R-T R.S. or R.C.E. No. <br /> Test Location t"Eb%A T=q t-ply O� 77�j ZD to Test Date/Time PCc�PAl� �►<!I, <br /> 4. El SANITATION PERMIT <br /> A O►y'i7d SO ST}IStD€ OF S�A/►�IS , �t GO ATtp�.►�j/�Z � �y11 <br /> o.4 Mi0rL X01` SO. MAr C/! 42p. AT 11. �T10� <br /> 3o nn 9 - <br /> Job Address/Location ,l -,� H-� }�lY�,-I <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 /> Home ownn_rorticanaedagent's signature c-,riifiesthefollowing,"I Certify that in the performance of the work for which this permit is issued,Ishallnot employ any persbi�; <br /> in such manner as to become subject to workman s compensation laws of California." <br /> ntrac':oi s hiring or subcontracting signature certifies the following: `I certify that in the performance of the work for which this permit is issued,I shall <br /> t ploy persons subject to workman's compensation laws of Califo,aia." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r` ordinances, state laws, anq rules and re ulations of the San Joaquin Local Health District. <br /> AP LIGANT'S SIGNATURE X <br /> ;0 <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 /> AMOUNT <br /> FEE <br /> -F <br /> LESS V,..:.r <br /> PRORATION •Sl roc <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 M e•I~ . <br /> '.Received by Date ReCetpl No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL 4AET4PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA"95201 4 <br />