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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) SEPTAGF
<br /> ENVIRONMENTAL HEALTH-PERMIT
<br /> LIQUID WASTE`
<br /> Applicationis hereby madeto carry on siness in the jurisdictional area of t San Jo quip Local Health Distr' ,
<br /> w Business Name (DBA) r Address ® �
<br /> I- Owner Address
<br /> r,
<br /> Firm Partners, Addresses and Telephone umbers
<br /> K Business Telephone No. ?� ��7 Emergency Telephone No. 4
<br /> a
<br /> Contractor Licence No
<br /> L Applicants Name (Print) � Tie . Date E� w tz.= �
<br /> Please check Applicable Category(1-7)-and Fill IntheRequired Information,,. 4 �, �� i•rt: �, _. :, � Y
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For.Juiy 1, -_._- June 30;.19 — _ w: Disposal Sites
<br /> Description(Make/Yr., Color)
<br /> Serial No CAL. License No:-•x k r n .-•_ "CAL. License Renewal No.
<br /> Capacity: _ ;` Gal., Weights &Measures Na. f -
<br /> Equipment Parking Address # ,
<br /> 2. ❑ Pl3MPER YARD ,t( �.^` �.=_.4.-.•.W �4 _
<br /> :For July 1, # June-30,-19.1 �,,, r qy' ': } i€
<br /> No. of Vehicles Stored! i I
<br /> No. of Chemical Toilets Stored Ri f
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S. or R:C.E. Name r •: e R.S. or R.C.E.No.
<br /> Test L cation Test Date/Time= '
<br /> .4. SANITATION PERMIT - 1 '�•
<br /> Job Address/Location } � XJ &f
<br /> 3Owner ° ..Address
<br /> ❑ SEPTIC K ❑ CESSPOOL LE4'CHIFIE
<br /> fVG LD EEP
<br /> • SFI"GE PI,T ' ❑ PACKAGE PLAINT
<br /> TAN •�
<br /> 9PERIVIANENT_ ❑ TEMPORARY NEW �0,REPAIR I ❑ OTHER
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30; 19 (IJ
<br /> Type ConstructionI Disposal Site u
<br /> r,
<br /> No. of Units Equipinent,Storage/Cleaning Location(s) '
<br /> 6. ❑ PACKAGE TREATMENT'PIANT, 'For 1, -June 30, 19 `
<br /> Operator'Narne °` '� )," Where Certified _-
<br /> Plant Location "
<br /> Plant Capacity t I No. Units Served
<br /> 7. ❑ LAUNDRY..For July 1, 'June 30, 19 �.
<br /> k is
<br /> SIZE: © Less Than 1,000 Sq. Ft„ a more Than 1,000 Sq. Ft.
<br /> .t,.. _ e w•a...-.,ww+.....+•r._„-..-r»� _ 5 _
<br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo.' ' .i
<br /> Home wnergriiCansEd.imnYaS1fleaturncettitiiasthefoltavying:"IcertiNtbpytinthe•rerformanceofthee;arkfo.whichthispermitis-isned:lshallnotemployanypr*^«.
<br /> in sur h.manner 85 tfI t1BCJITyF SUb10Ci t7 Y1'i C"1�r1'i C7r rp'F45a:IJ I i 16J6(y{r lrf A"a; y»
<br /> Contractor's hiring at sub•cnn pactrn, signuta,r� car#i'rdas ':he 'Ctt .v...D: ) t Fi¢' _}3v F?ii:fl tat; :11i 1)1E',tlork for Which this Pm.ilit j5 ISSLIBd,I Ila;1_
<br /> emptoypersons subject tD V;Cri!"alt s L'o pL Isaiio lavJs of '_hiCrlli .' [
<br /> ` I hereby certify that I have pared this application and t t the wor will be done in�accordatnce with San Joaquin County
<br /> ordinances, state laws, �eandgulat' s of the S aquin ealth •strict.- l
<br /> APPLICANT'S SIG�UA-URE X
<br /> j nvl la��
<br /> _FOR DEPARTMENT USE ONLY,,: . 3
<br /> Fee IS Due: ❑ ANNUALLY ❑:PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1 &Received By-January 31.-,,.,r-❑-Ju'1 I Received By_hAyt�l t
<br /> - _ ..... , .. .. ..-REMIT .
<br /> BILLING REMITTANCE $
<br /> BASE •'sf EXPLANATIONi AMOUNT DUE CHECKED
<br /> DATE- PI DXTE•"• REMITTED, AMOUNT—RE
<br /> 4
<br /> LESS -
<br /> PRORATION•1. r
<br /> PLUS
<br /> i.,PENALTY
<br /> THER
<br /> to
<br /> Date Receipt No. Permit No. 5suafft De Mailed Delivered
<br /> RETURN ALL:COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES' - '- 1601-E.HAZELTO .,P.O.Box 2009'- STOCKTON,CA 95201
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