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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 /> ,E' _ • LIQUID WASTE'
<br /> 'Application is hereby made to carry on busines in the jurisdictional area of the San Joaquin Local Health District
<br /> Business Name (DBA) �i4zrrP /5" S__92*I Address Lir ©f±�4.
<br /> z Owner '� Address
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No. '01d56 7 A Emergency Telephone No. - 4
<br /> Contractor Licence No.
<br /> Applicants Name Name (Print) �.�'a�+�. 4-ter% a i Title Date 2-
<br /> ,. ,r
<br /> q r t{
<br /> Please check Applicable.Category,(1-7)and Fill in the Required Information 'DL
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATfON (FOR EACH VEHICLE)
<br /> For July 1, -June 30, 19 _ Disposal Sites'
<br /> Description(Make/Yr., Color)
<br /> Serial No. CAL. License No." F CAL. License Renewal No.
<br /> Capacity ' Gal:, Weights & Measures No.
<br /> Equipment Parking Address
<br /> 2. El PUMPER YARD .,.,....._. ..... — _. ^� ��.. .�.. ���.,.... _ _ ,.ti........,y.. .. ,� �. ..-. ..
<br /> For July 1, June 30, 19 - - -
<br /> No. of Vehicles Stored I
<br /> NO. of Chemical Toilets Stored s ��
<br /> 3. ❑ PERCOLATION TEST t._...{
<br /> R.S. or R.C.E.iName R.S. or R.C.E. No.
<br /> Test Locationf Test Date/Time
<br /> A. IQ SANITATION PERMIT®�
<br /> Job Address/Location
<br /> Owner
<br /> J�� . Address �Aiia•� r .. ---r.a
<br /> /�,%� '
<br /> P9 SEPTIC TANK ❑ CESSPOOL'S-, ) LEACHING FIELD _ ❑ SEEPAGE PIT ❑ PACKAGE PLANT , .
<br /> PERMANENT 0 TEMPORARY NEW ❑ REPAIR ❑ OTHER ( (A
<br /> 5. ❑ CHEMICAL TOILETS For July 1,'-Jdhe%30, 19
<br /> Type Construction 3 �-i-Disposal Site
<br /> No. of Units u �� iEquipment Stolage/Cleaning Location(s)
<br /> .6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3Q;,i19 f.
<br /> Operator Name Where Certified _
<br /> Plant Location
<br /> Plant Capacity .� No. Units Served
<br /> 7. L3LAUNDRY For'July 1, -June 30_19
<br /> SIZE: ❑ Less Than11,000 Sq'Ft,, ❑ More Than'.1,000 Sq. 1=t.
<br /> ❑ D I Che icals Used/AmounVMo °'
<br /> ' e M aq?p@1go!la�Irrg�elti#Inslir¢falls�lrina "Irierftfyf'ialilrill�Il�rraffif nan�fllt w�'I'kflrwhl6frttlfs�lrrmltlolsslfed,l5hallnaicmplayanypersan Y
<br /> IP.5i1 IPi llpet a Iq �iif3 sul3jEirf In WUrktn rl s cerapP�,ahart law§a!
<br /> f�2R1i13_Cipr'g Kirin br s� �phlgrnia-, t
<br /> 1�InplBji @fJIQI3s }vQr E�ntr��I��s.s:Qn,tyre cerllftes the follolktng TI cBrflfy that jn.th9,119rferfriasrc�of lire work for which this permit is Issued,!shall
<br /> j IFfpR!is calnFepshail Saws of CailfpFlria."
<br /> I hFereby ertify that`I�have prepared this application and that the work'will be done in accordance with San Joaquin County Y
<br /> ordinances, state laws, and rules and regulations of the S aqum Local- h ' trict.
<br /> 4.
<br /> APPLICANT'S SIGNATUREX
<br /> _00, t a
<br /> FOR DEPARTMENT USE ONLY `
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' �. ❑ PER SITE ❑ EACH ❑ January 1 & eceived By January 31 ❑ Julq 1 &Received By July 31
<br /> - REMIT
<br /> BILLING REMITTANCE $
<br /> .BASE EXPLANATION AMOUNT UUE CHECKED
<br /> �- i� .DATE. , -,. DATE.-« . .REMITTED,.„.,w. .�
<br /> t .. w�,. �...,.. -. ..-AMOUNT"i" - 4�
<br /> FEE
<br /> LESS _ ^!
<br /> PRORATION V r
<br /> I
<br /> PLUS
<br /> .,PENALTY
<br /> OTHER I - -
<br /> OTHER :. -.a FSTIet ` 1 f�1�jffl
<br /> I, Received by - Date - Receipt No ' a Permit No, _ vance Date Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL-HEALTH PERMIT/SERVICES --"-41601 It HAZELTOM AVE.,P.O.Bo:2009 STOCKTON,CA 95201
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