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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION .
<br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE
<br /> ''. - ENVIRONMENTAL HEALTH PERMIT
<br /> 1 ., LIQUID WASTE l `-' '6
<br /> Application is hereby made to Ca ry o bus ess in the jurisdictional area oft San Joa uln Local Health District
<br /> ,T-Business Name (DBA),n
<br /> a Owner ( Address
<br /> dc
<br /> U Firm Partners, Addresses and Telephone Numbers
<br /> �
<br /> a Business.Telephone.No. �ffwQ / Emergency Telephone No.
<br /> a -
<br /> �Contractor Licence No.
<br /> Applicants Name (Print)�1r� ire _ && Title Date .
<br /> Please check Applicable Category(1-7)and Fill in the Required Information 1, . M, „
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, -. June 30,.19--.- _ — _Disposal Sites.
<br /> Description(Make/Yr., Color) �C
<br /> Serial No. CAL. License No. CAL. License Renewal No.
<br /> Capacity Gal.,Weights & Measures No. ----
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD .:
<br /> t
<br /> For July 1, June 30, 19
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets�;kg#ored
<br /> 3. ❑ PERCOLATION TEST Ih
<br /> R.S. or R;C.E. Name R.S.or M.G.E. No.
<br /> _ rr ,
<br /> Tet Lanon ` ` Test Date/Time
<br /> 4. }o�SANITATION PERMIT w��
<br /> Job Address/ Location .42 Sze- 4tL.V,t�i� AL-7rPICA -
<br /> ner t.L111-LtAM �� 1r19 Address
<br /> EPTIC TANK 055POOL 1 [3 LEACHING FIELD 11 SEEPAGE PIT PACKAGE❑ PACKAGE PLAN
<br /> } s sn
<br /> ERMANENT : 11TtEMPORARY ❑:NEW `' EPAIR, t ❑ OTHER
<br /> 5. 11 CHEMICAL TOILETS For July 1,*'June 30, 19 � r jY
<br /> I
<br /> Type Construction Disposal Site I � ..-4� � _. __ 19-1j
<br /> No. of Units -At Equipment StoragelCleaning Locations)
<br /> �, �. p
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, --June 30`19
<br /> p Z:
<br /> Where rtified
<br /> O erator;Name Ce
<br /> Plant Location s r I
<br /> Plant Capacity !� ! No. Units Served j
<br /> r }
<br /> 7. ❑ LAUNDRY For July 1, -June:30 19
<br /> I 1
<br /> X .
<br /> SIZE: #❑ Less Than 1,000 Sq. FtA ❑ More Than 1,000 Sq. Ft. )
<br /> 11 DRY CLEANING, Chemicals Used/AmounVMo•
<br /> k ,I'1Ot7184wner.ar}iGOnSRdagBnt'ssigt►attuacPrt:iEesSh:;fr:.Sawin-_"Ice;tfvth� titi-?£"; *"T Of'.l')1, "nf!Sr!=.;1iCi;ihi5���!i!ii15155112,'i,151!„IinGiE1T}Sl^,Jai!fp't_Cf
<br /> Ill SUCK manniei as to Sec^.^ie sjttq? t t�•4V.,"nrr:e""^'z"a! H� .1 3�++� v5 0 Ca�.!s�
<br /> 133"3
<br /> ;
<br /> "Cont'ractor's hiring or sr,$t•r•:^tra,tirc; s:p;,��k�:,�: ter= em.Yh f�i;owsa�. 'I ..krY„j tai"i tih t- ` ,, 13C 'D!ihhlYal'K for Which ii'i�' 1',,:t!., :1,I Silaf
<br /> employ persons 5ut;ec,tJ VyG knial s Co ilt cl ll 13::5 01 r�f;il il,a. .� "j a ! t
<br /> Thereby certify that I hay; repared this application and that the worn trvill e done in accordance with San Joaquin County-
<br /> ordinances, state laws, ules and regulati s of the San .,2.r,CO a District f, 1
<br /> APPLICANT'S SIGNATURE X
<br /> FOR DEPARTMENT U57E ONLY ��. • �,fS
<br /> Fee IS Due: ❑ ANNUALLY Q PER UNIT ❑ PER SITE ❑ EACH, �0'January 1 &,Received By January 31 July 1 &Redeived By July.31
<br /> .. .- - _ _.. - F +� a,, S, -..M - REMIT
<br /> ` BASE. EXPLANATION KILLING ; RERAITTANCE $ S AMOUNT DUE CHECKED
<br /> ' ''`•: yi.-. -!. .DATE ,: ..,,I ;.Of �E�: REeT TED ((( AMOUNT .
<br /> [ F
<br /> FEE �.. �, S
<br /> LESS :r.A 1,!' n i ”�`.`
<br /> PRORATION -�'
<br /> PENALTY - _ ,
<br /> OTHER • j ,.J i „J... ) a 'q �'+ '1 :4 >i' ."
<br /> OTHER
<br /> Lv3 [ Y C
<br /> Received by Date Receipt No. Permit No. Is u nce Date Mailed Delivered
<br /> f"--APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES "'1601 E.HA ELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 -
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