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 t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ;- LIQUID WASTE <br /> Application s hereby made to car on business in the jurisdictional area of the San Joaqul Local H alth Distr I <br /> rn Business ame (DBAI O/LD �� WILL" 5UB 0/oraoA/ Address '?-'-O Ff^Jf �f�_ • / fN0'E� <br /> H xiAlJa �e.Na.+A1 .fL�oeF.LG Address 95o rwe oRo P.y. X /oz Liriaed q.i.23L <br /> a Owner _ <br /> Firm Partners, Addresses and Telas <br /> eqphone Number <br /> 'a Business Telephone No. 117 7 - 3 e+ 1 Emergency Telephone No. 6- <br /> a <br /> Contractor Licence No. �7 <br /> Applicants Name (Print) r Dfa F AArJ NO Zl A(a Title ©WAf lE2 Date <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 cc <br /> For July 1, June 30, 19 \ / <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. KPIERCOLATION TEST <br /> R.S. or R.C.E. Name f< LTJ out"CDE.rt S S OC , R.S.or R.C.E.No. `- <br /> Test Location q r C A-f AI fo 0• f O Test nate/Time <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/AmounVMo. <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, and les and regulati s of t San Joaqui Local H alth District. <br /> APPLICANT'S SIGNATURE X <-eCpiJI'll ft <br /> So C13 <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �+ /r <br /> Received by f Date IReceipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.9oX 21109 STOCKTON.CA 95201 <br />