|
m Applications Will Be Processed When Submitted Properly Completed. sesure roaryn .r��+rr•- -• `� y
<br /> APPLICATION
<br /> r (For Non-Translerable:Revocable,and Suspendable) /1" SEPTAGE
<br /> ENVIRONMENTAL HEALTH.PERMIT
<br /> LIQUID WASTE
<br /> Application is hereby made to carry on business in the jurisdictional area of the n.Joaquin Local Heal District
<br /> Address Z�
<br /> cn Business Name(DBA)
<br /> Address
<br /> aOwner
<br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No.-
<br /> aBusiness Telephone No.
<br /> Contractor Licence No. Z t - Title Date
<br /> Applicants Name(Print)
<br /> Please check Applicable Category.(1-7)and Fill in the Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) y
<br /> For July 1, June 30, 19 Disposal Sites �]
<br /> Description(Make/Yr.,Color) r CAL. License Renewal No.
<br /> Serial No. CAL)Lidenses.No.
<br /> "• GaL, Weights &Measures No.'•
<br /> Capacity`^, t
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YpiRQ {
<br /> For July t, =— Jun 60, 19t
<br /> ,� `4 7 .fit e��
<br /> No. of Vehicles Sto�d t I
<br /> No. of Chemical'Tbilets Stored, �.r i fie�t7 Cr j
<br /> 3. ❑ PERCOLATION TEST, L�'+ � )
<br /> w,. +'� +> '1•f :d -Z R.S or R.C.E I0. i '
<br /> R.S. or R.C.E. Name - ' 'fN' `.,
<br /> I
<br /> j Test Date/T(rme N
<br /> Tet cation k w $ ) . t
<br /> 4.WSANITATION PERMIT
<br /> Job Address/Location 2 _ + (•
<br /> r ' Address 14
<br /> O ner �M1 ,._ ❑ PACKAGE PLANT�.�...,-.- v
<br /> j �^,EPTIC TANK ❑',CESSPOOL EAC11ING FIELD SEEPAGE PIT ti �-�
<br /> �] NEW k � REPAIR,---
<br /> 11
<br /> 0714ER
<br /> �-PERMANENT ❑t TEMPORARY I
<br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19
<br /> Construction r Disposal Site
<br /> Type I
<br /> No.of Units o Equi ment Storage/Gleaning Location{s)�
<br /> t ( ] S
<br /> g• C1 PACKAGE TREAT)kNT PLANT For July 1, -June 30, 19—
<br /> 1 \ _ Where�Cerrtifie t,
<br /> Operator Name
<br /> Plant Locationt �"«a' s '
<br /> f, " 4 N 1..—�-�'N0. C7nits Served -
<br /> Plant Capacity
<br /> 7. ❑ LAUNDRY For,- 1,-June 30, 19 r i
<br /> SIZE: Less Than 1,000 Sq_ . Ft., 13 More Than 1,000 Sq. Ft. r f
<br /> ❑ DRY CLEANING,an
<br /> Used/Amount/Mo. r r }
<br /> P 4,. i ne r 0 n i i Ml. p •sv
<br /> Hotrricrwn2CCrltcei:s�r4 ;g r s `"fit 4 e ti.i05 hEfoif `3":v P,13,'f�fft 1.`rlf>"fflr`1 i 1 l:s C i7 ilSi uCd.lvh�iJ f 012: 4 an Cr53
<br /> 1::such manner as to b6Cerfi.,5:.�3J..sl tG dV t ..�t�S i::,':ly)et'�° �1,�7• [ii�,�fii;vr
<br /> Contractor's hying or rub-contractinhJ SiSnRtt�e� carEle:es tlZa Following: "I certify that in.the petf8rrr once©i 1.ewcrk.for ,Ilii h this permit is issued,i shall
<br /> ' employ persons Subject to Y.'orkr,lari s ecr^0+'!i �ir1f1� wS "rii` ia,
<br /> I
<br /> I hereby certify that 1 have epared this application and that theiwork will be done in-accordance with Sac Joaquin County
<br /> ordinances, state laws, an and regul ns of the n dq cahNealth District.
<br /> APPLICANT'S SIGNATUREX
<br /> l FoRiDEPARTMENT USE ONLY j
<br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER,S T•E ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By l July 31
<br /> Y $ CHECKED
<br /> + 1 BIL♦•INC REMITTANCE AMOUNT DUE
<br /> BASE
<br /> EXPLANATION
<br /> i� DATE DATE REMITTED AMOUNT
<br /> �J
<br /> FEEtt
<br /> LESS
<br /> PRORATIONPLUS
<br /> 4 -
<br /> �.--PENALTY;..-,,.�w. a -
<br /> OTHER ,,,,�,_..�..,s�P+•..�.,. - .�.,..�,a.......,.r_ ....- �.. -. _.� .-
<br /> OTHER
<br /> Received by Permit No suance Date
<br /> Date Receipt No. ailed elivered
<br /> `i6lli E.HAZECTON AVE.,P.O.5<6.2009- STOCKTON,CA 95201
<br /> '.�
<br /> r APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,
<br />
|