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rt - Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> r -'APPLICATION 4.
<br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT.
<br /> LIQUID WASTE
<br /> L
<br /> Application is herAy made to car on business in the jurisdictional area of the San Joaquin Local Health District
<br /> rn Business Name ( `- AddressP. .
<br /> aOwner 4 Address �
<br /> Firm Partners, ddre
<br /> 'es
<br /> and Tel
<br /> Numbers r
<br /> CL `'+ lEmergency Telephone No.-
<br /> CL Business Telephone No. 1
<br /> X -- - -
<br /> Ii
<br /> Contractor Licence No.
<br /> " Title I a Date-
<br /> L ApplicantsAame (Print)
<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 f `�
<br /> Description(Make/Yr., Color) rr
<br /> Serial No, CAL. License No. CAL. License Renewal No.
<br /> Capacity Gal., Weights & Measures No.
<br /> Equipment Parking Address' A
<br /> 2. ❑ PUMPER YARD !
<br /> For July 1, June 30, 19
<br /> No. of Vehicles Stored
<br /> Na- of Chemical Toilets Stored
<br /> 3. .❑ PERCOLATION TEST -C
<br /> r
<br /> R.S.or R.C.E. Name r a R!S. or R.C.E. No. , - '•
<br /> ,0-
<br /> Test Location Test Dete/Time t '
<br /> ,
<br /> 4. 11SANITATION PERMIT
<br /> Job Address/Locati on6� '~
<br /> r ❑ SEPTIC-TANK ❑ CESSPOOL�, _"J�ne
<br /> LEACHING FIELD " "SEEPAGE PIT ❑ PACKAGEANT I❑ OTHER❑ PERMANENT ❑ TEMPORARNEW ( ❑ REP 'IR r 7
<br /> 5. ❑ CHEMICAL TOILETS For July , 30, 19 # ;a m
<br /> Site
<br /> Disposal s r
<br /> ! Type Construction Dis t p -
<br /> No. of Units ""�- Equipment-Storage/Cleaning Loca ions)
<br /> 6. 11 PACKAGE TREATMEWT PLANT For July 1;,`June 30, 19
<br /> Operator Name r- { k Where Certified
<br /> Plant Location
<br /> -
<br /> �., r ! No. Units Served
<br /> Plant Capacity I C 8[�►
<br /> r 7. 13 LAUNDRY For July 1, -June 30, 19_ y
<br /> � 1
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. El More Than,1,000 Sq. Ft. �.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> kOmnoUJnO�nsiE nn;e �n=,r,!"asiG^� iP ��e-1�?r'Fgtl+d 3^rr i �Iti5�tta-. "ig r,F, tire[ ols'fzz'r.,tGtYhispormitiSi55u d,ISha!!rDIernployarty person
<br /> li.51�Ci!Branner BS ED hCC%"i'>'allhj8ri:i - '< �. � 7r�1 7S?i� f17 S Ut ..n:i r- } �"`"�"•�..� ..-- 4
<br /> ConYractc:'s Flri:r;;t rr s:e�L•-a:c:r..rereT, �..i,-.. ,5 r... :i: . .r. { ,t- °.�[ r. �,I?�i'f .,,,,,.,,,".6 rdJl!.ID 7iCt]-i IS pemlilt iS Issued.I shall
<br /> E{iii'IDy9fS0116Ei:8;^G::J1':'J .`:!iici�S;:3�;:� �'i,.;.l;�:��:i'_ t
<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-ru d r tions an Joaquin Local ah District. E
<br /> APPLICANT'S SIGNATURE X
<br /> r
<br /> FOR DEPARTMEN 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 /> BILLING REMITTANCE �'�� AMOUNT DUE CHECKED
<br /> BASE EXPLANATIONDATE DATE REMITTED - •- AMOUNT V
<br /> t
<br /> FEE
<br /> 4L_ rte;
<br /> LESS P, a
<br /> PRORATION
<br /> PLUS c1 l Z -
<br /> PENALTY
<br /> OTHER
<br /> OTHER
<br /> Received by Date Receipt No. Permit No. Assuance Date Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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