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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TneAppucauen.
<br /> APPLICATION }
<br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE
<br /> I ENVIRONMENTAL HEALTH_PERMIT
<br /> LIQUID WASTE
<br /> Application is hereby made to carry on business in the'urisdictional area of_the San Joaquin-Local Health District.-,OF Business Name (DBA) i C -Address �—
<br /> z Owner f' O .Address 6
<br /> a
<br /> Firm Partners, Addresses and Tele hone Numbers -
<br /> aBusiness Telephone No. 5 Emergency Telephone No. _
<br /> Contractor Licence No. 2 " ";� •a - `�
<br /> Applicants Name (Print) ;� Tltke, �,_ Date- I
<br /> Please check Applicable Cat ory(1'-7)and Fill in th Required.lnformation
<br /> �1.=`❑-PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> # F,ar July 1,- - June30, 19-s Disposal Sites -
<br /> Descr ption(Make/Yr."Color)' --
<br /> 5erial No. :� r`°° —� r CAL. License No. CAL License Renewal No.
<br /> li
<br /> Capacit t Gal., Weights &Measures No.
<br /> Y ,
<br /> Equipment Parking::Add_ress
<br /> 2. ❑ PUMPER YARD, +
<br /> For July 1' ,�-.. Ju e 30, 19 `I' j ;
<br /> f No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored '
<br /> 3 ❑ PERCOLATION TEST t
<br /> ,R.S. or R.C.E. Name
<br /> R.S.or R.C.E. No. i
<br /> i -
<br /> Test Lo Ion Test Date/Time
<br />` q. L'J SANITATION PERMIT/ it
<br /> Job Add ss/Lo tion Ca�OtA Ji
<br /> - ;
<br /> Address f
<br /> Owner
<br /> ❑ SEPT TANK' ❑ CESSPOOL � LEACHING FIELD ,❑ SEEPAGE PIT 11 PACKAGE PLANT
<br /> ❑ PERMANENT _❑ TEMPORARY ❑ NEW M'REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June_30'711
<br /> Type Construction ll Disposal Site
<br /> ! No. of Units li Equipment Stor ge/Cl�e'aniirig,,Location((i) 1. i E r �' F
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 s rt = a
<br /> Where Certified
<br /> Operator Name I `''S;,
<br /> r ,
<br /> Plant Location _
<br /> Plant Capacity No. Units Served
<br /> I { i .
<br /> 7. ❑ LAUNDRY i ForJuly-1;-June 30, 19---------
<br /> SIZE: - ❑ Less Than`1,000 Sq: Ft., ❑ More Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1, , ' F, 3.
<br /> Hams nwlls�ratlFSBi'lSBdagent'svipnaturecwrtifi�r�theiplloyvrily:"iaottigilhatisb* 4%]itA(X41%e'w/ork*rwhichlhtsparrit3tisissucd,IshallnotemployagYpe
<br /> i-; IISskt''T'znrit`i :.. :,etiCrl !•.3Gt o ittMRSEt�"illi."Ic{C:�b;fi' r l fid
<br /> Cor+tr:ic.or's Fr;i1y� �r !u nlr�rr: cartl(�-. ° i '1" *"h t ukic
<br /> v;he: o:i ftir r;lice Acrrlit is IssueC t strait
<br /> empfti5 R6r5D;1:.'�- tt,L..C, i :.�,<�,r�-�.,.,r..:T X-,4r.,i.7Y56�t{'i+�E''?'Urili�.�- .`��__.__-• .• :^. ,... ` ,
<br /> � r>, ;
<br /> hereby certify that ; have prepared this application and that the work will'be done in accordance-with San Joaquin County
<br /> ordinances, state.laws, d rules and r ula ' ns of the San Joaquin Local Heal t District.
<br /> tAPPLICANT'S SIGNATURE X t
<br /> IA
<br /> FOR DEPARTMENT USE-PNLY I
<br /> Fee IS DU e:�❑ ANNUALLY -`I ❑ PER UNIT, ❑ PER SITE I ❑ EACH ❑ January 1 &Received By{January.31_,,,.�❑ July 1 8,-Received 8y July 31
<br /> s — REMIT
<br /> .BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHEC D
<br /> .,. - DATE - DATE f REMITTED AMO T
<br /> c � -
<br /> EEE s
<br /> 'a Permit No. - :p Issuan Date Mailed Delivered -
<br /> Received by Date - .Receipt No. —
<br /> APPLICANT—RETURN ALL COPIES 70! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95261
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