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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> { 0 (For Non-Transferable;Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEAL-TH_P,ERMIT
<br /> LIQUID WASTE
<br /> Application is hereb made to carry on business in the jurisdictional area.af the San Joaquin Local Health District
<br /> rn Business Name(DBA) �� a�_-,Address _ r
<br /> i Owner .- , , . Add ,.
<br /> „ .. ,,. � ress
<br /> U Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No., Emergency Telephone'No
<br /> Contractor Licence No. �� 3
<br /> 'Applicants Name (Print) ,Title .,. �Date 1
<br /> Please check Applicable Category(1-7)"and Fill in,She Required Information e s, �-
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> MFor'July 1, = ;June 30, 19'- Disposal Sites-
<br /> I Descript�'lon.(Make/Yr., Color)
<br /> Seriaki o. CAL. License No. - CAL. License Renewal No.
<br /> Capacity,— Gal., Weights & Measures No.
<br /> Equipment Parking Address `" " N' R A i
<br /> 2. ❑ PUMPER YARD `
<br /> For July I,— June 30, 19 #
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> 16
<br /> 3. ❑ PERCOLATION TEST '
<br /> R.S. or R.C.E. Name R.S. o�R.C.E.No.
<br /> Test Location t S Test Date/Time
<br /> 4. N SANITATION PERMIT . " « #.., ;• s + a..
<br /> ' Job Address/Location F�?�F, `l' d�D �'�.� r• .6_!57gF i4Al, --A
<br /> Owner -4+Q�A G_LP l E .✓ Address—I
<br /> { ❑ SEPTIC TANK CESSPOOL t X LEACHING FIELD A SEEPAGE PIT ❑ PACKAGE PLANT v
<br /> F ❑ PERMANENT ❑ TEMPORARY p ❑ NEW ," ISI REPAIR ❑ OTHER
<br /> I 5V,g❑ CHEMICAL TOILETS For July 1,_# June 30, 1.9
<br /> ( Type Construction x Disposal Site
<br /> I No of Units Equipment Storage/Cleaning Locations)� r
<br /> 6..,13 PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> r:r
<br /> Operator Name Where Certified _. ... . "
<br /> { i�f " - ' -
<br /> r Plant Location
<br /> li Plant Capacity wNo. Units Served
<br /> "7. LAUNDRY For July 1, -June 30, 191
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,'. ❑ More Than 1,000 Sq. Ft.
<br /> t
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> 7 T
<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 regulations of t n Joaquin.Local Health District. _
<br /> APPLICANT'S SIGNATURE X T '' ' .l ` '• �' Y
<br /> e>VMS. d"-,•� 1�.a{Y+ni ` ,�:� �S'..i_ e".', ,
<br /> - FOR DEPARTMENT USE.ONLY #`s
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH'• ❑ January 1 &;Received-By January',31, t❑"July 1*&Received By July 31
<br /> w BILLING REMITTANCE $ REMIT
<br /> BASE EXPLANATION AMOUNT DUE CHECKED
<br /> DATE .DATE - - REMITTED - AMOUNT
<br /> �G� 00
<br /> FEE
<br /> LESS f
<br /> PRORATION T
<br /> -
<br /> PLUS
<br /> "PENALTY
<br /> .. OTHER
<br /> OTHER
<br /> Received by Date Receipt No. Permit No - Issuance D d Mailed Delivered' ;
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERmurisERVICES 1601 .HAZELTON A .,P.Of Box 2099 STOCKTON,GA 95201 V
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