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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
<br /> :-Applicatillpirij9 hereby made t carry on busine in the jurisdictional area of the n oa in Loc Head4lr rict
<br /> y Business a ( BAJ Ue �. Address
<br /> aOwner Address
<br /> 1 Firm Partners, Addresses and le hone Numbers
<br /> CL
<br /> Business Telephone No. Emergency Telephone.No.
<br /> Contractor Licence No. �--
<br /> �Applicants Name (Print) Title,_.-e!j).4=J ^ Date
<br /> Please check Applicable Category (1-7) and Fill in the Required Information Y
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For"July 1, - June 30, 19 - Disposal-Sites --...--- --.-. C�
<br /> Description(Make/Yr., Color) _
<br /> Serial No. CAL. License No. CAL. License Renewal No. I
<br /> Capacity Gal., Weights & Measures No. 4
<br /> Equipment Parking Address - -- - — - r
<br /> 2. ❑ PUMPER YARD
<br /> t
<br /> 1. For July 1, June 30, 19
<br /> No. of-Vehicles Stored
<br /> No, of Chemical Toilets Stored t
<br /> 3. ❑ PERCOLATION TEST-
<br /> R.S. or R.C.E. Name I R.S. or R.C.E. No.
<br /> Test Location # t Date/T' e
<br /> 4. ❑ SANITATION PERM T OF
<br /> Job Addre s/ c ion 1
<br /> Wr 4 �— Address
<br /> SPTIC TANK ❑ CESS.OOL_0-_,LEACHING-FIELD -❑-SEEPAGE-PIT ❑-PACKAGE AN ♦ ,�
<br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑,OTHER
<br /> 5. ❑ CHEMICAL.TOILETS ForJuly I,.-June 30,19
<br /> Type Construction Disposal Site \
<br /> No. of Units (S)Equipment Storage/Cleaning Locatio '
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 L
<br /> Operator Name Where Certified -
<br /> Plant Location C
<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 5q. Fl. r
<br /> f ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> i � _1! -�•,•±i 4 s6><<ere•''i ^I '"r r.'IF'i1 1 •:-;- �_ i !Y,7, this permit i5-isGuc,; sl al nc,'-Fp!ay a,-Y Pe sed a�er.r:n16 owner or lice :
<br /> _
<br /> i;3::.•.Ch(nBRnP,f A t0 l#EeOiTIB 5Ul7lf'uf t:1'kdrlr� i15 f it.'�'rs,t
<br /> Certractor's iriring or sub-con'mct:ng rvg-saturn tho an;io v.hg, I Certify thui In the of:i1C wwk ior w .C,,t'iis Germif is i.^,s,letl,l sh afl
<br /> erpioy persons suhjeCt to wori:mar,s Ccrnpers.'.ien tarts vi Caiifc,mia:'
<br /> i hereby certify that I have repare this application a th t work will be done in accordance with San Joaquin County -
<br /> ordinances, state laws, a rule a regulations he n Jo u ealth District.
<br /> APPLICANT'S SIGNATURE'X
<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 /> +# REMITTANCE $
<br /> BASE � EXPLANATION BILLING R
<br /> �,.. AMOUNT DUE,— CHECKED ,
<br /> DATE ,,,� "DATE a �, REMITTEL)' AMOUNT-
<br /> FEE S -�
<br /> LESS �'...� .
<br /> PRORATION
<br /> PLUS
<br /> PENALTY i� —
<br /> OTHER-
<br /> .� rr.-•..r}gip..www'..4'+'..�++�` ... _ .e,.:�.... ry
<br /> OTHER 4 Q
<br /> t]
<br /> Received by. m' - Date Receipt No: - /Permit No: I uanc ate. Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIVSERVICE$ 1601 E.HA ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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