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<br /> Applications _
<br /> Will Be Processed When Submitted Pro er y ,
<br /> APPLICATION
<br /> . . -
<br /> (For Non-Transte�abfe,Revocable,and Suspendabie) SEPTAL-
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE J
<br /> in Local He 1 D t I
<br /> Ilcation i . reby made carry osiness in the'urisdictional area of the a
<br /> ApP" Address—
<br /> Stu
<br /> F Business Name (DBA) Address
<br /> aOwner. r'. -
<br /> U Firm Partners, Addresses andY,TP enc
<br /> I brJ, Emergency Telephone No.
<br /> a Business Telephone No. T� r Date
<br /> Title .. ,
<br /> Contractor Licence No.
<br /> Applicants Name (Print) r47 ^-
<br /> Applicable Category (1-7)and Fill in the Required
<br /> Please check App o _
<br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTWrIONN(FFOPRoEaCSites a VEHICLE)
<br /> 1 June 30;.19 ' No.
<br /> I Renewal
<br />� For July ,. CAS. License
<br /> Description(Make/Yr.,Color) CAL. License No.
<br /> Serial No.
<br /> Capacity
<br /> Gal.,Weights &-Measures No.
<br /> Equipment Parking AddressN
<br /> 2. ❑ PUMPER YARD r,. : e ¢f,
<br /> For July 1, June 30, 19
<br /> t ,t;
<br /> No. of Vehicles Stored # T _ t
<br /> ..•-.-7
<br /> t No. of Chemical Toilets Stored f J g}
<br /> f g ❑ PERCOLATION TEST"' . R.S. or R.C.E.No. I �J
<br /> R.S.or R.C.E.Name Test Date/Time '
<br /> f w,
<br /> Test Location ` } �-
<br /> 3
<br /> q, ❑ SANITATION PE
<br /> I;t1AIT "
<br /> Job Add sslL ation Address
<br /> Owner ' LEACHING FIELD SEEPAGE PIT PACKAGE PLANT.
<br /> SE `TANK ❑ CESSPOOL" ❑ REPAIR ❑ OTHER
<br /> NEW ", } S
<br /> PERMANENT" ❑ TEI+APORARY — ) "
<br /> pli y June 34, 19 f q
<br /> 5. ❑ CHEMICAL TOILETS r For Jul�1.` Disposal Site-
<br /> r 1, P.. ..r
<br /> Type Construction
<br /> Equipment Storage/Gleaning Loc atio
<br /> I No. of Units ns) '
<br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Wher. Certified.
<br /> Operator NameNA
<br /> °.
<br /> �"—
<br /> '_ Plant Location No. Units Served
<br /> i Plant Capacity
<br /> 7, ❑ LAUNDRY For July 1,-;June 30, 19 _x i
<br /> ❑ Less Than 1,004 Sq. FL } 0 More Than 1,000 Sq. Ft.
<br /> :SIZE: -' --
<br /> ❑ DRY INC USe. Amount/tufo 4 r r rTit is iss,.ecl,l s; em.p':oy L n r,
<br /> CLEANING,Chemicals ;,, � tul,ri•.^.'. Yf}�'"'
<br /> t'^'=ROyV7sCrLYr[iCsn:,�d-ng ° n -- crRrF ,..`:,^.ffnS40+.,=ng .�".E'ri`yl 'IPIE,.P(C il3rlC. bf'liCWt''Iir ci',ihS �
<br /> ;_vii manner Pis to becllfP2 au.1-3ct 101 J ,:'lan {1-11�e:�;Nii��r'lava Ci�� (' i:ld •g.•.,
<br /> L".-tractur's hiring or sub-ecA2-at•;ing s;gnaf:;re-certifies the ft+fl�w.ng:-'1 certify 4b min ttsc�Cit61e l^i? UI t 1C Vr'Crt for WI?ILII INE j QCI131t l5 i55L'E ,i s11dll
<br /> er:lploy persons subject to,rerknzr;rs cofflpers i6WI lFws"ot Ca ?ia:'
<br /> lifotli
<br /> I 1 prepared this application and that the work will be done in accordance with San Joaquin County
<br /> I hereby certify that l have p p
<br /> ordinances, state laws, an rules and regu tions o e an aquin Local Health District.
<br /> APPLICANT'S SIGNATURE X
<br /> l
<br /> FOR DEPARTMENT USE ONLY i &Received 13y July 31
<br /> 1 &Received By January 31. ❑ July
<br /> REMIT
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE > EACH January CHECKED
<br /> _ l BILLING REMITTANCE= REM TTED. AMOUNT 6;E AMOUNT
<br /> IBASE EXPLANATION ATE DATE .
<br /> r
<br /> d r
<br /> �'y1
<br /> FEE
<br /> LESS
<br /> PRORATION'
<br /> PLUS - / -
<br /> ' PENALTY
<br /> OTHER
<br /> OTHER
<br /> _ Is uan a pate � Mailed Oelivered�—
<br /> Permit Not-,`
<br /> Date Receipt No. � \ - .� t64t E.HAZELTON'AVE..P.O.Box 29D9 t'STOC1[TON,CA 95201
<br /> Received by
<br /> APPLICANT-RETURN ALL COPIES TO:""'ENVIRONMENTAL HEALTH PERMITlSERVIGES /
<br />
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