Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed..Be Sureo Sign The Application. ♦ / <br /> APPLICATION 1 `� <br /> 7 ' <br /> 4 on-Transferable,Revocable,and Suspendable SEPTAGE <br /> NVIRONMENTAL HEALTH PERMIT . <br /> LIQUID WASTE <br /> Application is hereby m et rry o iness in the jurisdictional area of the San Joaquin Local Healt/h/District <br /> o Business Name (DBA) 4.� _ Address e- <br /> Owner A •_G- Gifi Address <br /> Firm Partners, Addresses anhone Nymbers I• <br /> Business Telephone NEmergency Telephone No. <br /> Contractor Licence.,No. <br /> Applicants Name (Print] dL� - Title _644'"A Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) , ire <br /> For July 1, June 30;19 - Disposal Sites , <br /> Description(Make/Yr.. Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. I� <br /> Capacity Gel., Weights& Measures No. b <br /> Equipment Parking Address - J_ <br /> 2. ❑ PUMPER YARD V <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 /> Test Location Test Date/Time _ <br /> 4. ❑ SANITATION PERMIT / <br /> Job Address/Location L' <br /> Owner J2 �'6-5�' Address�� .F Gray ,�'r T,t.reY <br /> Q'SEPTIC TANK ❑ CESSPOOL VEACHING FIELD ❑ SEEPAGE PIT 0 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) —r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,.-June 30. 19 d' <br /> Operator Name - _ Where Certified rr+ <br /> Plant Location _ <br /> Plant Capacity - No. Units Served <br /> 7, ❑ LAUNDRY For July 1,-June 30, 1?. . <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 that I have prepared this application and that the work will be done in accordance with San Joaquin County f <br /> ordinances,state laws,and rules a L regu ions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Recelved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION - BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE- DATE REMITTED AMOUNT <br /> FEE JF <br /> LESS / <br /> PRORATION <br /> PLUS D <br /> PENALTY <br /> OTHER <br /> OTHER <br /> oq�l3 I a � I �9 <br /> ReceivM by Date Receipt No. Permit No. iwua ce Date M00 Delivered _a <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON. '95201 <br />