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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE / v
<br /> Application Is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District
<br /> F Business Name (DBA) F Address 577C72P4/
<br /> tOwner Address
<br /> J Firm Partners, Addresses and Telephone Numbers
<br /> Q. Business Telephone No. 7/ Emergency Telephone No. n1,
<br /> Contractor Licence No.
<br /> Applicants Name (Print) Title 6OiflTJt? Date_le=1 9Z
<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, 19 Disposal Sites
<br /> Description(Make/Yr., Color) (�
<br /> Serial No. CAL. License No. CAL. License Renewal No. �t~
<br /> Capacity Gal., Weights & Measures No.
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> Test Location Test Date/Time
<br /> 4. jl SANITATION PERMIT
<br /> Job Address/Location 4rOSS 4 ,eof— .� ST �7�C�c�,✓
<br /> caner ZL 3 Address 5��.�TF'
<br /> SEPTIC TANK ❑ CESSPOOL X LEACHING FIELD OrSEEPAGE PIT ❑ PACKAGE PLANT
<br /> PERMANENT ❑ TEMPORARY 9 NEW ❑ REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19
<br /> Type Construction Disposal Site
<br /> No. of Units Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> Operator Name Where Certified
<br /> Plant Location
<br /> Plant Capacity No. Units Served
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19
<br /> SIZE: 13 Less Than 1,000 Sq. Ft.,' ❑ More Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> ffomend�-1A•orJi^erl:,edagent'sef;,ne+if.ar,r; .. •gni^'F�, s �t, *� i
<br /> fn Sl:t;h{il„!,:;.r.u. . �. - ti_f:3''9C0rtlf) `1a 1,'iitlgperformanceolthework.or1,jv!:ch-h:S t ne 11 n �
<br /> Lecolae_uL . , 'i - 's nit a i
<br /> °t.otc.a .::•1t Gs.:f,lrr.,r ' G ss��.;,15h3..nct�m,'1,ay any person
<br /> 1040wiu;t: '1"(,;;iy Mal 4h the p@riG;rtia3�„ui ii i;Y.':�i-k��r r,i71tP.Ei?!5 pi;rll:li� „SIJe�,I Shall
<br /> �lilj7liijl j3::rs0ei,,Dill.}0Gi iL lYOrlCtli+'iiF 5 l,tr(:jit,;,,a3iil;1;IaYrS Gt C3tit311;td.• ! ,�
<br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County
<br /> ordinances, state laws, and rules and regulations of Joaquin Local Health District. ,2
<br /> APPLICANT'S SIGNATURE X
<br /> ac C - z
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januafy 1 &Received By January 31 ❑ July 1 &Received By July 31
<br /> BILLING REMITTANCE $ REMIT
<br /> BASE EXPLANATION AMOUNT DUE CHECKED
<br /> 44 DATE DATE REMITTED AMOUNT
<br /> FEE m
<br /> LESS
<br /> PRORATION
<br /> PLUS
<br /> PENALTY
<br /> OTHER
<br /> OTHER
<br /> Received by Date Receipt No. Permit No Is anc Date Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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