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'f # Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> " APPLICATI-ON
<br /> A'/t 10 For Non and Suspendabie) SEPTAGE S
<br /> ,1�1 Iff ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUIp WASTE.
<br /> Application is hereby made to carry on business in the jurisdictional area•of the San Joaquin-Local Health District -
<br /> NBusiness Name (DBA) Address -
<br /> i Owner ^a Address._ -3 u:elb f.PnT. •./. f�ho-__fs1`7�� !�
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> CL . -Enver enc Telephone No... -
<br /> CIL Business Telephone No..—. �y .5� °t7 -� _ g Y p
<br /> 1 Contractor Licence No. _ -
<br /> aa,/ �1 "�- Title f.s��/� Datey, g/���/��Z f
<br /> L Applicants Name (Print} . + _ - --
<br /> y.:,
<br /> Please check Applicable Category (1-7}and Fill in the Required Information r _ �r,;,Olg r , v f?` I . ! ` (�!
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> Disposal
<br /> i
<br /> Fbr July 1, �: - ,lune 30, 19��..:._:,w,.T _ p _
<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 VehiclestStored
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S.or R.C.E. Name
<br /> R.S. or R.C.E. No.
<br /> Test Location ' Test Date/Time
<br /> 4. 19 SANITATION PERMIT
<br /> 'Job Address/Location
<br /> Owner ~' d✓ [Fa Address w
<br /> r ❑ SEPTIC TANG ❑ CESSPOOL- TEACHING FIELD ❑ SEEPAGE PIT - ❑ PACKAGE PLANT
<br /> s ❑ PERMANENT t ❑ TEMPORARY ❑•NEW / ❑ REPAIR ❑ OTHER Sxlslz.-.
<br /> r 5. El CHEMICAL TOILETS For July 1, -June 30, 19ibl.>.sS, l"�y6T !�� ,Yy.=�fp3�Yr
<br />` Type Construction Disposal Site
<br /> r No. of Units Equipment Storage/Cleaning Location(s) Y
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> r Operator Name - — Where Certified m'-
<br /> Plant Location
<br /> Plant Capacity No, Units Served
<br /> 7. 11 LAUNDRY .For July 1, -June 30, 19 - - - -. _ . .� _ .,
<br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., T ❑ More Than 1,000 Sq. Ft. _ r
<br /> r ❑ DRY CLEANING, Chemicals Used/Amount/Mo. k \
<br /> } t I,-, �
<br /> Homoev7rne:n7lieenssc+ag�nxf rgnt�t.,re�srztimsthefe110; rg:"1 Certifytha tte. erferttan;eoft work for which thisGErmitisissced,l.shal!notemployanyperson
<br /> in such rracr.•- ... ;;,J :',7.,.e_i,.i��t .r. ,Ikrrrar s co,*ler:, ti ,:iaw�ci Ca.i;er..i i c�
<br /> L- - eITF, �I,.,. ..a�uC��::,.t,....,)(;,r,,. ..c.�.�pCl.5u�:'..,r ....��I�J hI{,,,lu. � Y ;tel 6rl'r• .-.Cf lN;IC,•ll-'�- i9 i55:1..(i,I shdli
<br /> hereby certify that I have prepared this application and that the work will be done in accbrdan ce with San Joaquin County
<br /> ! ordinances, state laws, and rules and regulations of the San J quin Local Health District.
<br /> . �
<br /> APPLICANT'S SIGNATURE,X i.
<br /> FOR DEPARTMENT USE ONLY-
<br /> Sl Fee I6 Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE _ ❑ EACH _❑ January 1 &Received ByJanuary 31 ❑ July 1 &Received By July 31..
<br /> I REMIT
<br /> BASBILLING REMITTANCE $ AMOUNT DUE CHECKED
<br /> , E EXPLANATION DATE DATE REMITTED -
<br /> _ _ AMOUNT
<br /> FEE _ ✓ �, J. 4 7� r
<br /> 1
<br /> LESS + +
<br /> PRORATION ' 41 SLY••. v[C '�I' V G
<br /> PLUS -L. . .Oif v.Mep ,� ✓V(/
<br /> PENALTY
<br /> OTHER
<br /> r ,.. OTHER - - - - -
<br /> ' -°1 �l-1Fs-Fsi a
<br /> Received,by Date Receipt No. Permit a . Issuance Date _ Mailed Delivered
<br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.90:2009 STOCKTON,CA 95201 -
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