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- . Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication h-.
<br /> APPLICATION
<br /> �. (For Non-Transterable,r Revocable, and Suspendable)
<br /> SEPTAX71!
<br /> ENVIRONMENTAL HEALTH,PERMIT
<br /> LIQUID WASTE '
<br /> Application is hereby made to carry on business in the jurisdictional area of the San JoaquinLocalHealth District,, ..
<br /> `Address
<br /> y Business Name ( ) �, /P�If pr f )r--e
<br /> -
<br /> J
<br /> OwnAddresser.
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> a Emergency Telephone,No.
<br /> a Business Telephone No. Y '•..
<br /> �'�� �s.,::a',.•t,�s.I•'.1 .� �—'-z'L ,.:1.:'i�. u ��;r.� :..., rt,,. V" �. l� ..
<br /> Contractor Licence No. ph Y u-Title
<br /> f { : + .� �F '` ' ' ' Date -�' u
<br /> LApplicants Name (Print) .,tis.. ._ }€• , _w , :�:r e,E 1 �.. f,.vcu ? lfe_ i vv - ..., p�
<br /> Please check Applicable Category(i-7)'and Flll in the Required Information :.n elc� rn.p7? ! rS;Ov: ;� `:�,qtr,w� ), ^+._
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i
<br /> For July 1_--. _ - June 30;_1.9: '�-• w--•-.Disposal
<br /> Description(Make/Yr., Color)
<br /> Serial No. CAL. License No. CAL. License Renewal No.
<br /> r
<br /> Capacity Gal.,Weights &Measures No.
<br /> Equipment Parking Address ; t
<br /> 2. ❑ PUMPER YARD' x
<br /> For July 1, June 30, 19 3
<br /> }
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored 7
<br />' 3. ❑ PERCOLATION TEST !
<br /> is R.S. or R.C.E.No.
<br /> R.S. or R.C.E. Name
<br /> Test Location r tl Test Date/Time
<br /> f' ❑ SANITATION PERMIT
<br /> Job Address/Locatio "-
<br /> Owner Address
<br /> SEPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT C1 PACKAGE PLANT-< -.
<br /> 5PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER a"
<br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �••rL
<br /> .I Type Construction Disposal Site
<br /> No. of Units Equipment Storage/Cleaning Location(s) #Y M
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,.19
<br /> ii x" Where Certified
<br /> 'Operator Name. 4
<br /> ti
<br /> Plant Location ,
<br /> Plant Capacity 1. No. Units Served r
<br /> 7. ❑ LAUNDRY For July.1, -June 30,19
<br /> SIZE: - ❑ Less Than 1,000 Sq: FL,. ❑ More.Than 1,000 Sq.`Ft. l
<br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo
<br /> r :.: ,
<br /> 'I hereby certify that I have pr are this application-a that the work will be,done in accordance with'San Joaquin County
<br /> € ordinances, state laws, and rules a regulations of t 0 in Local Health District. .� 4 ,. m
<br /> 'APPLICANT'S SIGNATURE X
<br /> FOR DEPARTMENT USE ONLY ry-
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER,UNIT- ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31
<br /> REMIT
<br /> BASE EXPLANATION i BILLING REMITTANGF $ AMOUNT DUE CHECKFD
<br /> 4-. DATE- DATE _REMITTED _ - AMOUNT
<br /> r� 1
<br /> -� 4
<br /> _ ,..FEE
<br /> LESS
<br /> PRORATION
<br /> PLOS -
<br /> 1 PENALTY..
<br /> OTHER
<br /> OTHER_ t �,,, ! _ i., _- _ •-
<br /> ive dDate Receipt Na Permit No. lssu nce We Mai d Delivered
<br /> -- - APPLI NT—RETURN ALL COPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES`- 1601 E.HA2ELTON AVE,,P.O.Box 2009 - 5TOCKTON,GA 95201
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