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Applications Will Be Processed When Submllted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH-PERMIT 4
<br /> LIQUID WASTE
<br /> Ap-plicatiomis hereby made to carry o mess in the jurisdictional area of the:San Joaquin caVF`i�alth Dis rict,/}
<br /> �/ l�
<br /> F Business Name(DBA) ry� �,�_ 1�-s1 __- y Address r
<br /> Ir r Address
<br />� a Owner C .... . .
<br /> Firm Partners, Addresses and T e y e tubers
<br /> CL
<br /> Business Telephone Na� � � Emergency Telephone No.
<br /> 4 Contractor Licence No. -
<br /> L Applicants Name (Print) Title _ Date
<br /> Jr
<br /> Please check Applicable Category (1-7)and Fill In.the Required,.information ,.. r ,,. ai,, n�•. _, �;; - }y
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) OCI
<br /> t For July -IN'- June 30,-19-- - `- Disposal Sites
<br /> Description(Make%Yr., Calor) -J
<br /> Serial No. '`- '"'" CAL. License Na' CAL. License Renewal No. f`-�
<br /> Capacity ti~"• - Gt'I'.�M,-ghts-&-Measures-N
<br /> Equipment Parking Address.
<br /> 2. ❑ PUMPER YARD'_' `' •,�' t r i ' \\
<br /> For July 1, June 30;,19
<br /> 'No. of Vehicles Stored
<br /> t No. of Ch
<br /> emidal Toilets;Stored
<br /> 3. ❑ PERCOLATION TEST'-,
<br /> R.S.or R.C.E. Name �={ R.S.or R.C.E. No- t t
<br /> � nr a <"•-fit
<br /> Test Location ° --r Test Date,/T�ime
<br /> 4. ❑ SANITATION PERMIT
<br /> t Job Addre ocation I
<br /> Owner t " Addresses/tt� ,' .r ' � r'v .
<br /> ❑ SEPTIC TANK ❑ ESSPOOL 9--tEACHING F LD igH5rEPAGE,PIT"Se,❑ PACKAGE PLANT
<br />+ &1rERMANENT TEMPORARY � IR O'-OTHERQ t' � i C)
<br /> 5. 11CHEMICAL TOILETS-.For July 1,-June 30, 19
<br /> Type Construction € —Disposal SiJe— -
<br /> No. of Units - Equipment Storage/Cleaning Location(s) i
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1 -June 30, 19
<br /> Operator Name •� - -. _- -- "- •{NP►ereY6®rtified s•', _- r *t
<br /> 3 f k l fM
<br /> Plant Location
<br /> Plant Capacity ) f No. Units Served "
<br /> i
<br /> 7. 11 LAUNDRY Forliuly 1, -June 30, 19. t - ;' A y•
<br /> ❑ More Than 1,000 5
<br /> SIZE: ❑ Less Than€1,000 Sq. Ft., q. Ft. ) ) i I
<br /> ©`DRY CLEANING, C�hejm�icals Used/Amount/Mo.
<br /> V/.` �„�r,�,� Gsl�cf�= I�\,� �I �xOsS`,I��j�'Q��'�`�• �y.�'��r�s`'� ,
<br /> hereby certify th f I have prepa this app ca ' and at t work will be done in acc,(rrdance with San Joaquin County _
<br /> ordinances, "state laws, and le ni3 re ul S a ui Local Health District. tt ff
<br /> APPLICANT'S SIGNATU ' 'a
<br /> r 'FOR DEPARTMENT-USE-ONLYT -
<br /> t# K r i 6 r r -. �.
<br /> Fee Is Due: ❑ ANNUALLY! ❑ PER-MNIT.' ❑.SER.SITE 4�/;❑EACH ❑ January 1,t -Re'eived By anuary 31 y.: ❑ July f4'Received By July 31
<br /> w _ _ J + REMIT
<br /> 1 "� BILLING REMITTANCE J$ .�} 'I
<br /> AMOUNTDUECHECKED
<br /> _ -
<br /> BASE �EXPLAN,4TION DATE\ —DATE -�--^-^REMITTED- 5 k 7 AMOUNT
<br /> •S; - ��`^""y� meq,
<br /> i .. •,. - '1 F - -cam \R ,�y` - _1 jf.
<br /> FEE d 4
<br /> f
<br /> LESS i' �._,_ _�. y..iM 14 •; j
<br /> PRORATION
<br /> r-
<br /> PLUS 1 t --
<br /> i PENALTY
<br /> 4 *5 4�
<br /> OTHER _ if s x : x't ! •�. - - - --
<br /> '' i
<br /> .-OTHER.
<br /> Received by Date Receipt;Nd._�` Perinit.No'�"" I suance•O to Mailed Delivered`
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON Ave.,P.O.Box 2oo9 STOCKTON,CA 95201`
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