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- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ^ A
<br /> I -- - APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE !
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE t ar
<br /> Application is hereby made to carry on business in the jurisdictional area of-the San Joaquin Local Health District-
<br /> Business
<br /> istrict-Business Name (DBA) Address y �'�.
<br /> aOwner Address {
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> 0. Business Telephone No.,---Oeg '-3?71 Emergency Telephone No., -
<br /> �u.
<br /> Contractor Licence No. �2.S274
<br /> Applicants Name (Print) L A0,9 i7 Tltle., f Date= 7 z
<br /> Please check Applicable Category (T-7) and Fill in the Required-Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r d
<br /> For July 1, ` - June 30,19 = -Disposal Sites - - `}--
<br /> Description(Make/Yr., Color) , ,y
<br /> Serial No. �" CAL. Lice'e- o. CAL. License Renewal No. ar/
<br /> i =
<br /> Capacity ._ 1r I Gal.,Weights & Measures No. F
<br /> Equi6ent Parking Address ) M v t►_ t, kN {'s,77,
<br /> .2. M PUMPER YARDS t[ I
<br /> For July 1 ' 6, June 309
<br /> No. of Vehicles Storedif
<br /> No. of Chemical Toilets:Stored
<br /> 3. ❑ PERCOL-ATION,TEST ,� ;\
<br /> R.S.torr B.C.E Name R.S.or R.C.E. No.s-�sem. - g s�i, ' "`� r• �i f?r�, ,
<br /> Tes Li ocafioft�n � 4 r -- --- ---Test Date/Time :y,~, 4 •,, ' 'TR
<br /> 4. {SANITATION PERMI J
<br /> Job rrAdd ess/Location
<br /> Owner — .S_7-�GNA• Address ,4w�A_- __,00 S G
<br /> ❑ SEPTIC TANK EI CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT
<br /> ❑ PERMANENTS D TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER
<br /> 5. D�CHSMICAL,TOILETS For July 1,-June 30, 19
<br /> .T peConstruction Disposal Site _
<br /> No. of Units : Equipment Storage/Cleaning Location(s)
<br /> -6. PACKAGE TREATMENT PLANT"Flir Jul9-1,=Juun ""30'19"— '"
<br /> Operator Name } + )• Where Certified '9
<br /> P rant Location 1 -0J I I —
<br /> I?lanl Capacity +( No. Units Served �.�
<br /> 7
<br /> LAUNDRY -FOr July1, -June 30, 19
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., . ❑ More Than 1,000 Sq. Ft.
<br /> ❑rDRY CLEANING, Chemicals Used/Amount/Mo.
<br /> Home ewttororTicen�edsttr?;'sls;grr_tfrer^ !f�s4!w1 certify rth2tinthe psrfarmanceofThe work torwhichthis Permitisissued.100not employ anyperson �
<br /> Ir such manner ds.lo b6co 11(?subj*",z)Y:3r k;ra,?.S of r,8i�:ilrfii8� I-
<br /> Contractor's hiring or Ptah-Co:.lrc.^°Mg aic'no-are cartniys s �tliovsr;rx: "I Certify Mat in the performance 6l Me wort(for Which this Permit is issued,I stfall ,
<br /> employ persons subject to wog k,rain s compt;Csa6ur0aws ilia."
<br /> T.1
<br /> s
<br /> hereby certify that I'have prepared this application andthat the work will be done in accordance with San Joaquin County
<br /> ordinances, state laws, and rules and regulations of the v. aquin ocal Health District.
<br /> APPLICANT'S SIGNATUREX IC
<br /> 7 FOR DEPARTiNENTUSE ONLY
<br /> Fee Is Due: ❑ 'ANNUALLY ❑e PER UNIT ❑ PER SITE ❑ EACH i❑ January Received By January 31 ❑ July 1 &'Received By July 31
<br /> BILLING - REMITTANCE $ REMIT
<br /> + -BASE �EXBLANATION..�, -.__� AMOUNT DUE CHECKED
<br /> - _ �ii DATE •'•DATE -IREMITTFD - AMOUNT
<br /> FEE A 7
<br /> f y
<br /> LESS
<br /> 'PRORATION-
<br /> PLUS
<br /> PENALTY - — - `T�; - �� - .� •3
<br /> ..OTHER
<br /> OTHER _ —
<br /> Received by ,.; Date- .Receipt NoPermit No. Is uanceate Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BO][2009 STOCKTON,CA 95201 I
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