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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> i APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable) y SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT '�
<br /> LIQUID WASTE
<br /> Applicatio hereby ma to car on busmesIn the jurisdictional area of th an J quin oval Health Dist t
<br /> F Business Name (DSA)_ � A ' 07sf - Address O l r
<br /> aOwner ,Address
<br /> Firm Partners, Addresses and Tel Numbers
<br /> IL
<br /> Business Telephone No. �f� _ Emergency Telephone No, y-
<br /> Contractor Licence No. ��
<br /> LApplicants Name (Print) el, r Title Date _ --
<br /> Please check Applicable Category (1-7) and Fill in the Required Information. .;
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C)
<br /> For July-1, June 30, 19 --Disposal Sites
<br /> Description(Make/Yr., Color) t
<br /> Serial No, CAL. License No. CAL, License Renewal No.
<br /> •X'=9
<br /> Capacity'�a Gal., Weights &Measures No. I
<br /> ,
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD.#
<br /> For July 1, June 30,.19
<br /> No, of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION^TEST--^. .tzk" t l
<br /> R.S.or R.C.E. Name R.S. or R.C.E. No.
<br /> ZI
<br /> Test cation Test Date/Time t'
<br /> 4. SANITATION PERMI
<br /> Job Address catipn
<br /> i! - o
<br /> Owner 1 Address 4 t
<br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PUNT
<br /> ❑ PERMANENT TEMPORARY
<br /> ❑ NCW _ . -M-- «• ! t
<br /> REPAIR., , ❑ OTHER �"
<br /> 5. ❑ CHEMICAL TOILETS For:July 1,-June 30119 F
<br /> Type Construction Disposal Site e,
<br /> No. of Units ) Equipment Storage/Cleaning,.Location(s) t t I r
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> Operator Name } Wher+a,`Certified
<br /> 'Plant Location
<br /> Plant Capacity } allo.-Un is SerVed a #
<br /> 7. ❑ 1,.
<br /> LAUNDRY For '-.June 30, 19 a 1 +� 4.
<br /> SIZE: Less Than 1,000 Sq. Fl.,°�' ❑,More,Than 1,000 Sq:.Ft. {
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> ti' ca.� Vii•-5vr•z, :�f '-�"A.�,'.s �,.!t`.' ) „••w�`�:i..-.,..�:�,�„, I
<br /> I hereby certify that 1'have prepared this application and that the-work will be done-in accordance with San Joaquin County
<br /> ordinances, state laws, a d rules and repiqlation i uin:Local Health District.
<br /> APPLICANT'S SIGNATURE X
<br /> I 'FOR DEPARTMENT USE ONLY -
<br /> Fee Is Due: 111ANNUApLLY ❑ PER UNIT ❑ PER SI-(E ; ❑ EACH ❑ January 1 &Received By January 31 Q July 1 &Recei4ed By July 31 J,
<br /> } REMIT
<br /> BASE EXPLANATION - BILLING 1} RF¢I TANCE '$ AMOUNT DUE CHECKED
<br /> „•� „;, - _. ,„,,,„,,,��,DAT tM 'f•.�AREMITTED 7 AMOUNT
<br /> WTI FEE / 11
<br /> LESSi '� f, s a
<br /> PRORATION r
<br /> PLUS
<br /> PENALTY
<br /> t t
<br /> OTHER _ g
<br /> OTHER r.
<br /> r�
<br /> Received by Date Receipt No. -Permit No. Iss nce Date Mailed Delivered -
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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