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; .- Applications Will Be Processed When SubmittedProperly
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is ereby in�e to carry on business in the jurisdictional area of the S�aann,`oaquin Local Health District,
<br /> - f rUL Address
<br /> NBusiness Name (DBA) r� Addresses
<br /> Owner ,
<br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No.
<br /> aBusiness Telephone No. n�
<br /> Contractor Licence No. _ Title Date
<br /> l L Applicants Name (Print) w'
<br /> 1 T and-Fill in the Required Information � ; - ; a :; -yOfi
<br /> Please check Applicable Category ( - )",
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _
<br /> f June 30, 19 Disposal Sites
<br /> [ For July 1,
<br /> Description-(Make/Yr., Color) - CAL. License Renewal No. f
<br /> Serial N6. CAL. License No. i
<br /> CapacityGal.,Weights &Measures No.
<br /> !
<br /> Equipment.Parking Address
<br /> 2. ❑ PUMPER YARD -k ;
<br /> For July 1, June 30, 19
<br /> ! No. of Vehicles Stored l
<br /> • Y i
<br /> 'No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E.No.
<br /> a _ 1
<br /> R.S. or R.C.E.Name Test Date/Time 6`
<br /> Test Location ; f
<br /> 4. ❑ SANITATION PERMIT �/ b A G`
<br /> r!
<br /> Job Address/Location G ► r
<br /> Owner F S�� ?�-`=� Address r
<br /> ,,te�tt ❑ CESSPOOL LEACHING FIELD, ❑ SEEPAGE PIT ❑ PACKAGE PLANT .
<br /> 14' SEPT; TANK ❑ REPAIR OTHER
<br /> ( a
<br /> 13 PERMANENT ❑ TEMPORARY ❑ NEW
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 .Y C
<br /> Disposal Site
<br /> Type Construction r
<br /> No. of Units Equipment Storage/Cleaning'Location(s)' ,
<br /> f.
<br /> 6. ❑ P.ACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified i
<br /> Operato"Name
<br /> Plant Location 1 J' No, Units Served ,
<br /> Plant Capacity
<br /> T, ❑ I=AUNDRY For July 1,.-June 30, 19 0\:" } ,
<br /> SIZE: , ❑ Less Than 1,000 Sq. Ft., ❑ More Than-1.000 Sq FL, w
<br /> DRYCLEANING.Chemicals Used/Amount/Mo- - 1
<br /> ►lortls4rlrP ' f + r - -:t3 r ;' }" ,".^,D„�n'h'J:'{SD :Fiiiul �iIS E"ri'.it13155'v?C,1Sl�IlfiOtE( ploy any PCrson
<br /> in sIICh niam'1' s In bucomcl
<br /> Contractsr s IY ifvc c: .s�- r > t, ��.• y„' :i,e pertcrri Duce o;lite-,No,,k for which this permit is issued,i shall
<br /> ( I hereby certify .I have prepared this application and
<br /> that -the --be-dobe-in accordance
<br /> thatwith San Joaquin County,
<br /> ordi n ances P.state laws, and rules and r latio F f the Sari;Joaquin Local Health District.
<br /> c
<br /> APPLICANT'S SIGNATURE_ X .,rst s {
<br /> j { t
<br /> x ¢ ' FOR DEPARTMENT USE ONLY. K
<br /> "ay ` ; 4 H ❑ January 1 8 Received By`January 31 ❑ July 1 &ReceivdBy July,31
<br /> Fee IS Daae: ❑J ANNUALLY _C ❑ PER UNIT—,_. ❑ PER SITE
<br /> ❑ EACH REMIT
<br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED
<br /> t , BASE EXPLANATION. DATE DATE --':REMITTED AMOUNT
<br /> i F f r
<br /> FEE. „
<br /> LESS
<br /> PRORATIONt
<br /> PLUS
<br /> PENALTY _.
<br /> OTHER
<br /> f
<br /> t
<br /> - issuance Date Mailed Delivered
<br /> Received by .w Date a t Receipt No- `'=.v '•� �..PerrnihNouance' `t661 E.H uance N AVE:,P.O.aox 2009 STOCKTON,CA 95101
<br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMITISERVICES
<br /> i
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