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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transfe►able, Revocable and Suspendable)
<br /> ENVIRONMENTAL HEALTH-PERMIT SEPTAGE .w
<br /> LIQUID WASTE
<br /> Application is hereby made to carry on busi ess in the jurisdictional area of the 5 n Joaquin Local Health District
<br /># y Business Name (DBA} �.��/ '�f.3f� .S%a�YS 'Address ^ + t
<br /> Owner t Address
<br /> J Firm Partners, Addresses and Tele hone Numbers T u
<br /> aBusiness Telephone No. "' QC 7 Emergency Telephone No. �..
<br /> Contractor Licence No. _
<br /> L Applicants Name (Print) /��/�� ��ev Title Date�Zo
<br /> Please check Applicable Category (1-7) and Fill in the Required Information �W
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1
<br /> For July 1, June 30, 19 Disposal Sites
<br /> Description(Make/Yr., Color)
<br /> Serial No. CAL. License No. 'CAL. License Renewal No. ( Al
<br /> Capacity Gal.,Weights & Measures No. ` `
<br /> Equipment Parking Address '
<br /> 2. ❑ PUMPER YARD,—,�.,.r. .. - �,.� ,. . ". __ _ .• .. - ,
<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. Mame R.S.or R.C.E. No.
<br /> .Test Location Test Date/Time"
<br /> 4. SANITATION PERMIT
<br /> Job Address/Location— 4!Y,3��V _Y/�Cik-7`Z1,VC
<br /> Owner /70,/ A?igR S'e>' _ _Address
<br /> ❑ SEPTIC TANK ❑ CESSPOOL v„� �`LEACHING FIELD "9 SEEPAGE PIT ❑ PACKAGE PLANT S
<br /> ❑ PERMANENT ❑ TEMPORARY [1 NEIN -'- .19REPAIR,,, ❑ OTHER
<br /> 5. 11CHEMICAL'TOILETS For July1 'June 30,, 19 (f.?
<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 # V,
<br /> Operator Name f Where Certified
<br /> Plant Location
<br /> Plant Capacity ` - 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 /> © c; i_z,q/.Amount/M6
<br /> IN�E,i i lAaf? r sy tt�lr�Cs�fnri"ibjt'cto Wofv is,a s cc��m�n� 4 q� ,a3 n-rWV orma. t
<br /> Ct'cafifha.! ctre ifrrtnaticea#tllesuorfafofiuJhi is speimitisis,u ,i5fla11natemployaaypersoR
<br /> ti�i 2»t'S hitrRg br :^,trD c,00 taetrn
<br /> Lfti !D' 9 '•grmture certifies the fotfo%vin } f - x
<br /> PeTS0145stiflitU 10 TV rMadil's cortlpo aiion laws of C tfifornia:' g' Wlffy that itt the
<br /> i►erlormattce of file work ter which this permit is issued,f shall
<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 San.JoagegLo I Health District. -
<br /> APPLICANT'S SIGNATURE X
<br /> FOR DEPARTMENT USE ONLY t
<br /> _ Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH,,e��❑January 1 &Received By January 31 ❑ July 1 8,Received By July art
<br /> I
<br /> REMIT I
<br /> BILLING REMITTANCE $
<br /> BASE EXPLANATION � AMOUNT DUE CHECKED ?
<br /> DATE DATE REMITTED AMOUNT
<br /> FEE
<br /> LESS O
<br /> PRORATION '23 �1
<br /> PLUS
<br /> PENALTY
<br /> OTHER T
<br /> OTHER i .
<br /> -a=3-8�
<br /> Received by - Date - ,Receipt No. - Permit No. , ;*� ..Issu ce Date Mailed Delivered
<br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ''�' 1601 E.HAZELTO AVE. .Box 2009 ' STOCKTON,CA 95201 f
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