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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) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE f
<br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local.Health District .1
<br /> rn Business Name {DBA) F1.Of��E GrID017 Address 1�- �, AY.OP4E ST ' ' G�ra�/ ~
<br /> z Owner Address
<br /> 2 Firm Partners, Addresses and Telephone Numbers
<br /> qBusiness Telephone No.- � �' 7/. ,. Emergency Telephone No. .
<br /> Contractor Licence No.
<br /> _ � rnttir
<br /> L Applicants Name (Print) �}/J� �'t30�. ._"---..-..-._ -v Title x. Date 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 - C�
<br /> Description(Make/Yr.,Color) r
<br /> Serial No. CAL. License No. CAL. License Renew al~No. s
<br /> Capacity t, Gal.;Weights & Measures,Nb. r t
<br /> Equipment Parking Address.
<br /> .2. ❑ PUMPER YARD .. 4
<br /> For July 1, June 30, 19
<br /> No. of Vehicles Stored r t
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST v 'r"'" } t
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ,
<br /> Test Location } A Test Date/Time }
<br /> 4. 9 SANITATION PERMIT -•k
<br /> .Job Address/Location r��la1�d:: M4A1,4 57aG,4 -&A,)
<br /> Owner .��/JZC1 �C'AS✓'���gwl Address :_14-zV jti16 r+:4lDyrl.4. C �7a:cJ
<br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT E
<br /> ❑ PERMANENT ❑ TEMPORARY ❑,NEW REPAIR kOTHJrR /MT7" 0ze- AlZwal �P 0�,.
<br /> 5.
<br /> El TOILETS For July 1, -June 30, 19 ' IQ7JMJ S,�,5P77C- 7Wi41W_1 .
<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_ f .
<br /> Operator Name _Where Certified
<br /> Plant Location R t€
<br /> Pians Capacity r ^No. Units Served e,
<br /> 7. ❑ LAUNDRY I For£July 1r-June 30,•19
<br /> i
<br /> SIZE: ❑ Less Than';1,000 Sq:Ft.,, ❑ More Than 1,000 Sq. Ft. 3 <'
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ""' i -
<br /> In Uri
<br /> u r ,4 7AM a',«'M?cerkfar%*,iCt1 ttsia permh eS any iswed,I shall not"joy a Gff>Ol
<br /> Bt!
<br /> r^'•Y i1j'. rbrOrie•Stk,)0El't8..,,�,�., .. ..w:�q,�y...rkrd; a 1,�;,,,„psi G.�.:,iw,c�,ca• _rwi•;..y: "i I..Gcdsiy tlsai 1n ttie .fora w"*f 117£wofk(Lr41liO this PCrmit is issued,I shall '
<br /> I hereby certify that l 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 pt4kW San Joaquin Local Health District. v '
<br /> APPLICANT'S SIGNATURE X �' .� All
<br /> #
<br /> 03
<br /> -
<br /> • Y
<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 /> BILLING REMITTANCE $
<br /> BASE EXPLANATION }AMOUNT DUE CHECKED
<br /> P DATE- DATE REMITTED - - AMOUNT
<br /> FEE cll� r.
<br /> LESS
<br /> PRORATION - - -
<br /> PLUS
<br /> PENALTY
<br /> OTHER .
<br /> OTHER
<br /> Received by Date (Receipt No. Permit No. ss ce Date Mailed Delivered
<br /> r
<br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVIi1 - LTON AYE.,P.O.BoPC2009 STOCKTON,CA 95201
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