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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> (Far Non-Transferable, Revocable, and Suspendable) SEPTAGE g
<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. Yx ,
<br /> OF Business Name(DBA) Address T
<br /> z Owner » _
<br /> - Address
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> K Business Telephone No..` " Telephone No.
<br /> .Emergency
<br /> Contractor Licence No.
<br /> L Applicants Name (Print) Title - Date,
<br /> k _ -
<br /> Please check Applicable Category 0-7)-and,.FIII"in,the Required Information,} # E 4t3 , TE
<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 No, CAL. License No. CAL. License Renewal No.1
<br /> Capacity "" Gal.,Weights &-Measures No..
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> II
<br /> For July 1; June 30, 19 Nil
<br /> No. of Vehicles Stored l r
<br /> No. of Chemical Toilets Stored
<br /> 3. PERCOLATION TEST; R.S. or R.C.E. N .R.S. or R.C.E. Name
<br /> !� G
<br /> Test Location ,z3 D/s?S ®� l�9• Test Date/Time
<br /> 4. ❑ SANITATION PERMIT a-kr.,Iat1t_,
<br /> Job Address/Location
<br /> Owner Address
<br /> ❑ SEPTIC TANK -❑ CESSPOOL,- -"❑,LEACHING FIELD, ❑ SEEPAGE PIT ❑ PACKAGE PLANT-
<br /> .0 PERMANENT ❑ TEMPORARY P ❑ NEW © REPAIR ❑ OTHER t}`
<br /> 5. C] CHEMICAL TOILETS For July 1, -June 30, 19 tis
<br /> Type Construction Disposal Site
<br /> No. of Units t Equipment:Storage/Cleaning Location(s) rr
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 W
<br /> Operator'Name A - Where Certified _,...__..
<br /> Plant Location
<br /> Plant Capacity No. Units Served
<br /> 7. ❑-LAUNDRY For July 1, -June 30, 19
<br /> SIZE: ❑ Less Than 1,000 Sq: Ft., ❑ More Than 1,000 Sq.Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> k?�m�a e.erlaen c}agent's signaturnrArtifac�ct}tt+T os�r; :"tierE��.TTa•:rid.ep,x#t�r�an€Erefiheworf(Orvtichthis permit isissued.Ishall not empfay any P., 1
<br /> in s11ch manna,as':o become subject to lruorkmari� ctn ae+ *acca ia:;s of^afit rrf "
<br /> Contractor's hiring or',ui cCzi;ac`ihp signatw, :iia i, "t. �-r�,wga�k��hS,�FfUrffiaRC�G;tt►etiverkiorsvhirhitais"permitisissuet!,#shall +
<br /> employ persons subject to woskrta:ts cumparisaiiin:taws;►f Califarrt&L,
<br /> i 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 rules and regulations of the San Joaquin Local Health District.
<br /> APPLICANT'S SIGNATURE X
<br /> FOR DEPARTMENT USE ONLY ` f
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &.Received By July 31
<br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DREMIT
<br /> UE - GEMIT
<br /> r DATE DATE, - REMITTED- - - AMOUNT
<br /> 00
<br /> FEE CKED
<br /> of � :
<br /> r
<br /> LESS ? • '
<br /> PRORATION - t •- -
<br /> �.
<br /> PLUS .
<br /> PENALTY
<br /> OTHER ..
<br /> 1
<br /> OTHER
<br /> 'Received by pate Receipt No. Permit No. Issuance 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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