|
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application,
<br /> APPLICATION
<br /> (For Non-Transferable;ReYOeable,-and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Applicatio 2§her by matd�e to dar business in the jurisdictional area of the an Joaq�in- o l.Health District
<br /> F Business Name.(DBA) Address
<br /> cOwner—. _ _ Address _.
<br /> 1 Firm Partners, Addresses and T e~hone Numb rs
<br /> a.
<br /> a Business Telephone-No. - 'Emergency Telephone No. _ )
<br /> Contractor Licence No. r I
<br /> L Applicants Name (Print) •� ,Title; Date,
<br /> Please check Applicable Category (1-7) and Fill in the Required_Information . * ,°f �q,:.._ t•:r , �.„,,- '- ,�:., r, y#� =1c] :,.:�r. /
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION FOR EACH VEHICLE
<br /> For July 1, Juri30, 19 w� '-• Disposal Sites )
<br /> � e - — - `
<br /> Description(Make/Yr.,Color)
<br /> Serial No. CAL. License No. ,- :r CAL. License Renewal No. .
<br /> Capacity Gal.,Weights & Measures No:
<br /> Equipment Parking Address' i
<br /> 2. ❑ PUMPER YARD
<br /> 'Ror July 1, June 30, 19 � d
<br /> No.of-Vehicles Stored•____ s ' 'r +' : .
<br /> No. of Chemical Toilets Stored s '"
<br /> 3. ❑ PERCOLATION TEST e
<br /> -� ; .1 R.S. or R.CfE. No. "
<br /> R.S. or R.C.E. Nam .. .,,� '�- ,r+'� 43 ,,' - � , 4 S.. _.... )
<br /> �4
<br /> Test ovation Test Date/Time
<br /> 4. JW SANITATIOf4,PERMP
<br /> Job Address/ 'cation �.r f ,� r+-� - 0
<br /> Owner '' Q, �>1 � _��� _.- Address'
<br /> )K SEPTIC TANK ❑ CESSP&L LEACHING FIELD -SEEPAGE PIT ❑••P-ACKAGE PLANT:
<br /> ❑
<br /> PERMANENT ❑.TEMPORARY �NEW � ❑ REPAIR OTHER ,_01
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30 19
<br /> ;Di
<br /> Type Construction`'' sposal Sit'g . �
<br /> No. of Units t E Stora
<br /> Equipment ge/CleaninglLtication(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,'1'b{ `*
<br /> Operator Name r - Whe a Certified ri
<br /> Plant Location
<br /> Plant Capacity y No.'01hits Setrye
<br /> I
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 f .
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> I hereby.certify that 1 Piave prepared this appl" nand tha)fhe-work will be done in accordance with Sari Joaquin, �Jnty
<br /> ordinance's-state laws{and rules an lati s o h an Joaquin Local Health District. �3. ; f
<br /> , Karn•' :
<br /> APPLICANT'S SIGNATURE
<br /> FOR DEPARTMENT USE ONLY - -
<br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El,January 1 &Received By January 31 ❑ July 1 &Received By July 31
<br /> BILLING REMITTANCEg 1 REMIT
<br /> BASE EXPLANATION AMOUNT DUE CHECKED r
<br /> DATE- DATE — 'IREMITTED-- L�, t AMOUNT
<br /> FEE k e z• y�f't A
<br /> F � }
<br /> LESS , } _NI_
<br /> PRORATIONPLUS
<br /> t Y
<br /> PENALTY "'E ,•-•.' .i '`•,,^4� 2.
<br /> ` OTHER
<br /> OTHER .. .. o .•: b . # �- Ca a •.3 i
<br /> i4
<br /> Received by Date Receipt N6�_ Permit Nae�� *suanc4I Yafe , e&T Delivered
<br /> 'M1
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHTpt WSERVICES.. ' €�,:1609,E:[1AZELTON AYE.,P. Bax 20 9 STOCKTON,CA 95201
<br /> Y
<br />
|