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 /> Application is hereby made to carry on business in the jurisdictional area of the San.Joaquin Local.Health District r <br />,F Business Name (DBA) F2eyD1s•Gr P Address /?�� ir�AOGE .S•v— - <br />`z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. - <br /> LApplicants Name (Print) _Title Date��a��Z <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 Na CAL. License No. CAL-(License Renewal'No. �.. - <br /> Capacity Gal., Weights & Measures'No'"'"""`!i <br /> Equipme t Parking Address <br /> 2. ❑ PUMPER YARD,- <br /> t It IRS t �a1 N <br /> For July�1T June 30, 19 Vic. _ i <br /> No. of V(hicles Stored <br /> No. of Chemical Toilets Stored > t I I I <br /> r ►S <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R:C.E.-Name R.S. or:R.CE. No. -r-ok ��- '" 1 ; t <br /> Test LocationTest Date/Time <br /> 9. ❑°SANITATION PERMIT f <br /> Y <br /> Job Address/Location y'17S7Z40�"'.'�'r5'��� <br /> Owner 0—B,Y &&2A161 ' <br /> � Address 44 ,G�J; <br /> 9// Tis�•t/GL�w�Q� 1e�;'S7ZV 1C7T1 c� � <br /> E] SEPTIC TANK [3 CESSPOOL �LEACHINGaFIELD X. SEEPAGE P T 0?PACKAGE PLANT <br /> ❑ PERMAN NT ❑ T 0RARY ❑ NEW REPAIR ❑ OTHER <br /> 5. _ ❑ CHEMICAL'TOILETS For July 1, -June 30, 1;9 <br /> Type Construct on- Disposal Site 4 rr i <br /> No. of Units r - Equipment Storage/Cleaning Location(s) °: �f <br /> 6.- ❑ PACKAGE TREATMENT PLANT For July 1, -June 30;',19%-*"w'-%,>F M . <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity j No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ' <br /> SIZE:.:e'❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> R <br /> EAWch <br /> nsraMXTrasto� ►t'ssdr a*rn�cswrtr'z�-s!rot�l x+nq: �^nst.•i '• ,.tti r^! tiCC the yo Cfs i y <br /> a Wt5jW94&Y.fKt[T:Srs .ri:4jh;: -sir:: '�.ii1lrijl. 5,0prtsl s, nt w fl;f�rw S fllaTgrntltlslsgu�e� I-'� Er.-.St-`;?i;fC'y'pr�e,M <br /> ,c r <br /> +.crli:y irsi:.i..i ii1E�L'rtGfii7 ^(,Q cf iii$,.°;%!Arlt fCf YF;ildlt tftll3� rn.,a '. � i AfrAf� ' <br /> L`/1155;.'�;°wi1�SAW aa.+isrl$L3fYpfS';.�,�:731:3J::Sff1�„lu.isSit:l:. - ,. <br /> 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 rules and regulations of t oaquin Local Health District. <br /> APPLICANT'S SIGNATUREX + <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 Juiy 31 <br /> BILLING REMITTANCE $ REMIT <br /> ;BASE EXPLANATION AMOUNT DUE CHECKED <br /> �-• r�- DATE DATE REMITTED AMOUNT <br /> FEE y <br /> LESS <br /> PRORATION — - ,- - - s <br /> PLUS <br /> PENALTY "OTHER <br /> OTHER <br /> Received by Date Receipt No PermitNo� Is ance Date Mailed Delivered . <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1901 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> h <br />