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Applications Will Be Processed When Submitted Properly Completed. be Sure To Sign The Application.
<br /> 3 G`'' ► �� APPLICATION " 9.
<br /> (For Non-Transferable; 'evocabke,'and Suspendable) - . ,:4, .,SEPTAGE + y
<br /> / ENVIRONMENTAL HEALTH PERMITS—T D'DfJ .�"i�Ja 'D�< LIQUIDWASTE:.. �r ; ..-_� ? " t 2 ,
<br /> Application is hereby made to carryon business in the jurisdictional area of the San.Joaquin Local Health District
<br /> OF Business Name (DBA) DA PARR[S4 SOKIS o U
<br /> aOwner J Address .. .
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No. Emergency Telephone No.
<br /> Contractor Licence No. 7_1 {
<br /> Applicants Name (Print) T Title �AQAC ER Date t�;�'"'S7- -
<br /> Please check Applicable Category {1-7) and Fill in the Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July-1, June 30,-1'9-- �-Disposal Sites —
<br /> Description(Make/Yr., Color) _ I
<br /> Serial No. CAL. License No. CAL. License Renewal No. a
<br /> Capacity' Gal., Weights& Measures No. ;f
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19 i
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST _t
<br /> R.S. or R.C.E. Name . 'r'' R.S. or R.C.E. No.
<br /> Te t L cation '`Test Date/Time
<br /> 4. SANITATION PERMIT
<br /> Job Address/Location
<br /> Owner _Ny'I 1 ! w Aj ) -C��i1:�ST:.: Zzt>rm-LAddress V. 2�.C
<br /> R"SEPTIC,TANK ❑ CESSPOOL .,y-,'�LEACHING FIELD 13SEEPAGE PIT PACKAGE PLANT
<br /> PERMANENT 11 TEMPORARY E NEW ❑ REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL TOILETS' For July 1, -June 30, 19 Y
<br /> Type Construction Dispo'sal,Site, ` t
<br /> No. of Units Equipment Storage/Cleaning Locatidn(s)f
<br /> w.
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> Operator Name Where Certified
<br /> Plant Location _ 1 1
<br /> Plant Capacity .x• No. Units Served f
<br /> 7. ❑ LAUNDRY For July 1,-June 30, 19
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. k {
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO.
<br /> Fft� e swnerarficenscdagent's signaestracer;;tir„the fonewrng "I certify Thal il,heperfoamanceatihswork/th ' issuett.Ishall noiemployarryperson
<br /> in suet manner as to bes�rte subject to wi r;m a:;'s rulnpWsation laws of California;
<br /> Contractor's hirini or sub-oen>racripa s'-gnatum cerWim the 3otlowing:.,'i wtity thak in the performaich this permit is issued,I shallemp€ay persons,subject=aoworkman'sootnpeni aijonlaws,ofGSiiiarnia-"- ,-�--0,1 f ,_,) ''V I hereby ceitify,that9 have pYepared thisapplication and that the work will b`e done inSan Joaquin Countyori non es,statelaws, a rules and re ations. he Sari J jn Local Health Dist
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<br /> L•APPLICANTS SIGNATURE.X -
<br /> tfu"\44\l l
<br /> N 4 _ _ ,FOR DEPARTMENT U�WY
<br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH &Recewed By January 31 ❑.July,1 8 Received By July-3t
<br /> }- ti r_"z, - - REMIT
<br /> BILLING ANCE $
<br /> -, BASE EXPLANATIONDATE J TD. ' 'AlMoUNTDUE CHECKED
<br /> AE REMITTE AMOUNT
<br /> SIC
<br /> FEE
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<br /> 5i-
<br /> ! ti
<br /> _ F
<br /> LESS
<br /> PRORATION
<br /> PLUS .
<br /> PENALTY,_,_,a .. _
<br /> i
<br /> OTHER
<br /> i
<br /> . OTHER
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<br /> Received by Dale ,Receipt No. _ Permit Nom. + Issuan a Date Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERI:N sERVICEs 1601 E.HAZELTON AYE.,P.O.Boa 2009 `STOCKTON,CA 95201
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