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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application.
<br /> APPLICATION `
<br /> (For Non-Transterabie, Revocable, and Suspendable) SEPT1aGE
<br /> ENVIRONMENTAL HEALTH=PERMIT
<br /> LIQUID WASTE T
<br /> Application is hereby made to carry on business in the jurisdictional area of the-San Joaquin Local Health District. .
<br /> yBusiness Name (DBA) •Q � h ,.1 Address �-
<br /> r
<br /> z Owner Address
<br /> J Firm Partners, Addresses and Telephone Numbers -
<br /> a Business Telephone No. Emergency Telephone No.
<br /> Contractor Licence No.
<br /> Applicants Name (Print) 1ti 1 )Nf Title I"t' S �"+�� - Date
<br /> NA 1 Z' a- ��' r
<br /> ._ -�
<br /> Please check Applicable Categorp(1-7).and Fill in the Required-information , J ,•4 Y- p :rr r i
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, = ` June 30,-19 ------C'-, --;- Disposal Sites--
<br /> Description
<br /> ites 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 s r
<br /> For July 1, June 30, 19
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored �' €
<br /> 3. ❑ PERCOLATION TEST
<br /> -
<br /> R.S. or R.C-E*Name fit-t R.S.or R.C.E. No.
<br /> Test Location J Test Date/Time > -
<br /> 4.X�SANITATION PERMIT r - a ,
<br /> 11 1
<br /> Job Address/Location
<br /> Owner ALFP�b N e_-AID ,y { I Address,� 5A X.[_.
<br /> •❑ SEPTIC TANK ❑ CESSPOOL ❑;ACHING-FIELD t=1 SEEPAGE,PIT ❑ PACKAGE PLANT
<br /> E}PERMANENT ❑ TEM_ PORARY ❑ NEW ©`REPAIR ❑ OTHER
<br /> 5. ❑1 CHEMICAL TOILETS For July 1,-Jun 30, 19 4 �� c` ,L
<br /> Type Construction ^^" Dis'po_sal Site', 8 1
<br /> No. of Units ° Equipment Storage/Cleaning Locatiori(s)
<br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �( i
<br /> Operator Nann'e i.�,Where'Certified
<br /> e it
<br /> Plant Location
<br /> No. Units Served '' c
<br /> Plant Capacity 11
<br /> 7. ❑ LAUNDRY For July 1, -June•36f1'9
<br />� SIZE: ❑ Less Than 1,000 Sq;. Ft.,-10's-J] More Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. � c
<br /> k,orneosvneror!ieensac ar r a :, 1� rt nft, , tlactoltrv+in� Irertit that in?heperform-anceofthe workfor tvhic ihispermitisissued,Ishallnotemployanyperson
<br /> lin+such manner As tD bcc6 u [e�tYLt 'e Hien t m11-,Vs of California
<br /> yQlltruCtor•S phi?i^� Ii j2ht T-„rr!.�-r,.•.r`C r� s, $- 'eAc�irtsr:—t i E"I'ifar t111�Irl IS'e�'erf�s71n�1:l C:e-3f Ih 1•.'Cl'It fDr Which this permit i5 issued,l S1kall'f i
<br /> Brfp.Q�!-pqrSolis S �8i tG L Irl''fk„' b, 1XL.,, a:l'.! uF ..��
<br /> Aereby certify that-If have Prepared this application and that the work will be done i#'accordance with San Joaquin Cou� 4
<br /> ordinances, state laws, `nd bled and regu tons of the„San oaquin ocal Health District�'4
<br /> _
<br /> APPLICANT'S SIGNATURE X
<br /> L1K . T - .
<br /> .1
<br /> 1F FOR DEPARTMENT USE ONLY F -
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER-UNIT' ❑ PER SITE 13 EACH .❑ January 1 &Received By:January 31Q.' ❑ July 1 &Received By July 31
<br /> 3 ' �' €-
<br /> REMIT BILLING REMITTANCE $ .l '•' i t
<br /> t
<br /> BASE, EXPLANATION AMOUNT DUE CHECKED
<br /> .-., .¢!' DATE _-,�, «,DATE— REMITTED--. 'AMOUNT,.t:-
<br /> FEE 4 _ - l
<br /> e r .
<br /> LESS
<br /> PRORATIDN i -
<br /> PLUS
<br /> PENALTY a
<br /> ER J
<br /> + OTHER r7'
<br /> Received by Date 1 . Receipt No. ,Permit No. Issuance Date Mailed - Deliv red ,�
<br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAdELTON AVE.,P.O.Box 2409- STOCKTON,CA 95201
<br /> .. _._. -�' `f lam`-/r`��•ilj
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