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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)
<br /> SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Applicat'o 's hereby made in carry on bus' ess in the jurisdictional area of th ar}�Joa in Loc ealth rict .
<br /> (f k
<br /> rBusiness a (DBA) C Address. t f
<br /> aOwner . .a- Address
<br /> J Firm Partners, Ad esses and T lep one Numbers
<br /> CL Business Telephone No. � s ,Emergency Telephone No. -
<br /> Contractor Licence No. 7 -
<br /> Applicants Name (Print) C _ -Title Date I 1P -
<br /> Please check Applicable Category (1-7) and Fill in-the Requlred,.lnformatfon It, r, Y
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, June 30, 19 -Disposal'Sites
<br /> Description(Make/Yr., Color)
<br /> Serial No. - CAL. License No. CAL, License Renewal No.'
<br /> s
<br /> Capacity Gal., Weights & Measures No. v
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19 .
<br /> No. of Vehicles Stored I
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑"PERCOLATION TEST ' r�
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> Tet Location = Test Date/Time
<br /> 4. SANITATION PERMIT ) '
<br /> Job Addr /Location d 19 r I
<br /> Owner - Address
<br /> EPTIC TA K CESSPOOL CKLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANTS
<br /> ❑ PERMANENT ❑ TEMPORARY E EW REPAIR ❑ OTHER x Q
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19
<br /> Type Construction Disposal Site
<br /> No. of Units Equipment Storage/Cleaning.Location(s) L�
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> Operator Name Where Certified:
<br /> Plant Location )
<br /> Plant Capacity T No. Units Served
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - -
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑'More Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/'Amoun't/Mo.
<br /> Horrleowneror3iranser±p3e�'•'.;:ir�r:;.tur�c9�:e,�&#rlvfotlo��ri.. ICCrvth:, , t' - � � - _ 1
<br /> 9. 17 neer,G;r=•ailrettillCvd3rkfpft,hichtfispermtti_.isst!ed.Istlailrrot2mplryanypers�n
<br /> in=uch manner as to oerom << C lc -';$atl�r7 tc 5 f?,+ y
<br /> Contractor's hiri _In,
<br /> t
<br /> employ perSGrS soil eCt E ,•� 7 c 1� '3� 3a i L'�""ii' r ,may `., j C,;:;, ,v�...:I`,i tl;C 7ECEGI E?'.:ili �i iliC?^l6 IS t �;'� I .
<br /> j 0 V .Py.;.,C..?�,&.,5 t f, c7•.._:,'f!'M,;:�I„!? �j _ 7 or:4'i7iCi1 f Iv p6rm11 is{S5€!e(t,l 511 t7}, <
<br /> -I hereby certify that 1 have ar this application that a work will be done in accordance with San Joaquin County
<br /> ordinances, state laws, a rules an regulations th an J al Health District.
<br /> 1
<br /> APPLICANT'S SIGNATURE _
<br /> ... FOR-DEPARTMENT USE ONLY ,
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ❑ July 1 &Received By July 31-
<br /> f REMIT
<br /> BILLING REMITTANCE # a $
<br /> BASE EXPLANATION � AMOUNT DUE CHECKED
<br /> - : - - DATE -DATE 1 REMITTED- - - - .AMOUNT
<br /> FEE
<br /> LESS r - - 'F•` IF
<br /> PRORATION - - - - -
<br /> PLUS
<br /> PENALTY
<br /> r OTHER
<br /> _OTHER
<br /> Received by Date Receipt No. Permit No. Assuanc ate Mailed Delivered- i
<br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITlseRVICES., 1601 E,HAZEL E.,'P.O.Bar 2009 STOCKTON,CA 95201 - 1
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