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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> - APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable)
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> / SEPTAGE
<br /> LIQUID WASTE
<br /> Al
<br /> Application ' by made to carry b iness in the jurisdictional area of the San Joaquin Local Health District
<br /> Business Name Aa Address C2 C,J!
<br /> z Owner atf. Address c2 .1;;11, 0'ey z2ti•
<br /> a
<br /> J Firm Partners, Addresses and Tele one Numbers
<br /> aBusiness Telephone No. .2 Emergency Telephone No.
<br /> Contractor Licence No,
<br /> LApplicants Name(Print)_ Title �r�.>1c f_ —PWS Date �f
<br /> r r . 'E*S T�C C � :r,rR SERVICE
<br /> OL}'
<br /> Please check Applicable Category (1-7) and Fill in the Required Information Ci.,;.,:.P:;,,. �E)',p , �:, „-,,,,
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) SCS:_ C'I, C^i=5. J52f5
<br /> For July 1, June 30, 19 Disposal Sites
<br /> Description(Make/Yr., Color) i
<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. ❑ 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. 14ANITATION PERMIT01—
<br /> Job Address/L
<br /> Owner o ation
<br /> _
<br /> Address
<br /> ❑ SEPTIC TANK:;' ❑ CESSPOOLLEACHING FIELD *SEEPAGE PIT ❑ PACKAGE PLANT �
<br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR , [ MOTHER
<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 /> 0, 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 that I have prepared this application and that the work will be done in accordance with San JoagUP
<br /> ordinances, state laws, and rules an regulations of the San Joaq In Local Health District.
<br /> j r
<br /> APPLICANT'S SIGNATURE X
<br /> n • 263 So. Oro � Stockton, Calif. 9520.5
<br /> 1.,R.a•.•�� PIS.463-3209 Contractor's Lic.#25717.7,
<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 /> - REMIT
<br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED
<br /> DATE DATE REMITTED AMOUNT
<br /> FEE L� 5 -
<br /> LESS
<br /> PRORATION -
<br /> PLUS
<br />[ PENALTY
<br /> r -OTHER -
<br /> i
<br /> OTHER .'� ....
<br /> Received by�,�, - to i. Receipt No. Permit No. -Issuance to Mailed Delivered
<br /> II _ APPLICANT-RET.URN.ALL COPIES'TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT_ON AVE.,P.C.Box 200y -S OCKTON,CA 95201
<br /> r - :-_ s 'rk.ty .moi. . .;•~ Y" - - - r � � - �
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