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 /> Applicati is h@rebs made to Carry y business in the.lurisdictio I area of the ra al in L al Healttl DistClct <br /> r `duagi 1 (:OIILTOI 1129 CtIt�Ori 1. ���.3 d. ;Iiia tCi AVc�. Modesto Ca. <br /> y Business me DBA r �dPess <br /> i Owner-- ev p'menCo. Address `hattTi Ave. , Oakland, Ca. <br /> Firm Partners, Addresses ad Telephone Numbers4 1 5) 655-3299 <br /> CL Business Telephone IN- <br /> 7209')527-4940_7 Q65—$37$ Emergency Telephone No. (209)527-4940 <br /> N/A — Eri ineerin —Testin — Ins ctzan Firm <br /> Contractor Licence No. 9 9 9 f <br /> L Applicants Name (Print) O'C'I. by JESS WRY Title Engineer/,.,_—�L� 7/2$ 8$ <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. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored _ <br /> 3. El PERCOLATION TEST (HEMPSTEAD COURT SUBDIVISION) SU-87-21 ' ` t 7` <br /> R.S. or R.C.E. Name Quali.tY Control Inspection. R.S. or R.C.E. No. <br /> Test Location Sp't' Map Test Date/Time Will <br /> c$.._ o <br /> 5/5/88 <br /> 4. ❑ SANITATION PERMIT <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 /> I hereby certify hat I have prepared thiapplicp6Uon and that the work will be done in accordance with San Joaquin County <br /> ordinances, state and r les and reciulatio4 df the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX <br /> Jebsr P.R. <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 �/ �~ `• s� ) <br /> V f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receded by 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.Box 2009 STOCKTON,CA 95201 <br />