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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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District
<br /> Business Name (DBA) r
<br /> 4,011llmwZ> Address /!J.OPZE S771 S7aG,�Tt�ir�
<br /> aOwner Address
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No. 6S'__"21 Emergency Telephone No
<br /> Contractor Licence No. 1622!rA76 )
<br /> LApplicants Name (Print) z� �- TIED Title �T Date
<br /> Please check 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
<br /> Description(Make/Yr.,Color)
<br /> Serial No. CAL. License No. CAL. License Renewal No.
<br /> Capacity Gal.,Weights&Measures No.
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S. or R.C.E. Name R.S.or R.C.E.No.
<br /> Test Location Test Date/Time-
<br /> 4. g SANITATION PERM_U
<br /> Job Address/Location4Z
<br /> Owner Addres,,,,����s,,,,////
<br /> ❑ SEPTIC TANK ❑ CESSPOOL ,LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT
<br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER CP
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Q
<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
<br /> Operator Name 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�(11 ,CI•imigals Used/Amount/Mo
<br /> .ln sa� tete ,;;r, �rr �• ,�p- c;�, •» t�.*.,,,.� /^�
<br /> a tYr s-a+ct,r ac*irYt� , t, .t7.„4
<br /> .( PkiY Pv s �t•�r rrk� r , ria t"r¢ 1�:�Y� I ' :flat
<br /> ��i��,�y.�a.la,..�u,,,„a.,s.,us�„ .•.a..4a..� t'rir;
<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 rules and regulationsJoaquin Local Health 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 /> BILLING REMITTANCE $ REMIT
<br /> BASE EXPLANATION AMOUNT DUE CHECKED
<br /> DATE DATE REMITTED
<br /> AMOUNT
<br /> FEE
<br /> LESS \
<br /> PRORATION
<br /> PLUS
<br /> PENALTY JJ
<br /> OTHER /
<br /> OTHER
<br /> 6 -
<br /> Received by Date Receipt No. Permit No. Issuance Date Mailed ADelivered
<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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