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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) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is hereby made to carry on business in the'urisdictional area of the San Joaquin Local Health (strict
<br /> to Business Name (DBA) D-A- RAIM �OA35 _Yj&u � Address ��• I��'�� �
<br /> z Owner Address—
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> CL
<br /> Business Telephone No. U��- �� '7 - – Emergency Telephone No. .
<br /> Contractor Licence No,
<br /> Applicants Name (Print) �_T_As 1--� L i S Title � � - Date
<br /> Please check Applicable Category (1-7)and Fill in the Required Information x i �v:
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1; lb June 30, 19 Disposal Sites
<br /> Description(Make/Yr., Color)
<br /> Serial No. CAL. License No. CAL. License Renewal No.
<br /> Capacity Gal., Weights & Measures No. -
<br /> Equipment Parking Address "- r
<br /> 2. ❑ PUMPER YARD „ f ,
<br /> For July 1, c June 30, 19
<br /> No. of Vehicles Stored 1
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S. or R.C.E. Name r R.S.or R.C.E. No. ;
<br /> Test Loc ten ` Test Date/Time 3 -
<br /> 4. to SANITATION PERMIT
<br /> Jots Address/Location � c� p�"i
<br /> Owner s *•� t� t L1 '� Address
<br /> r*� SEPTIC TANK- ❑ CESSPOOL O LEACHING FIELD" ❑ SEEPAGE PIT ❑ PACKAGE PLANT (r�
<br /> C�`rRMANENT °❑ TEMPORARY 11NEW ,� "-Y� 8 REPAIR OTWER' +, -x j 0 +rLr� OV
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30 19
<br /> Type Construction` Disposal SituF
<br /> No. of Units .3 '"4Equipment Storage/Cleaning Location(s)
<br /> . 6. ❑ PACKAGE TREATMENT PLANT For July7, -June 3D, 19'
<br /> Operator Name + Where Certified {
<br /> ^'Plant Location
<br /> i Plant Capacity No. Units-Served
<br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 `
<br /> SIZE: ❑ Less Than 1,000 Sq.Ft.,, }0 More Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. m �
<br /> FiArn9OLYnerCr i a°. tl•x prh r F F
<br /> c^ �-,��� • r } thnf�Fl�'rr�ne Jcerti,yt„at in the perfermLrlceoithev�orkforrrhichthispermitisissuad,lshal?!not employ any person ,
<br /> ir'.such-mar?I1G_ .S.t^hgr� lj.i,.,,9�!�(£i,�n`S.i.�Ii1�.;r54:iU,1 rUY?4 J`y�=!e'Ok'i Id. 1 •"d•
<br /> Csrntracto.'o•Ni-Aq qr �.,,�'t' ,;+;,r.wr;;rc cr.is ler Sl•e €a?fOtving: "I °rtii}'that in She pertwmanue of the-.tof? fer,,vNch tNs i1£rR1ft Is issued,I shall
<br /> ernpi i}@rsu.5 a,;;i;� ,.�SlJ:};�.":l',+.`'', li.r_._�,._„!-15'{;;Ut Ca;,tCFE7„z. .y
<br /> _.., ._ �:
<br /> I hereby certify that I hav prepared this application and t at the Ark will be done in accordance with San Joaquin County
<br /> ordinances, state laws, d ule nd regulat' sof th K!��oaquin oc I Weal District.
<br /> ot
<br /> APPLICANT'S SIGNATURE X ,
<br /> ,�,5 FOR,DEPARTMENT USE ONLY j
<br /> Fee Is Dile: El ANNUALLY 1^1 PER UNIT ❑ PER SITE __% ❑ EACH.�r- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31
<br /> ” REMIT
<br /> BILLING p REMITTANCE $ ie..
<br /> BASE � EXPLANATION AMOUNT DUE CHECKED
<br /> C� DATE DATE REMITTED; AMOUNT
<br /> FEE
<br /> LESS
<br /> PRORATION
<br /> PLUS
<br /> PENALTY'
<br /> OTHER
<br /> Received by Date— Receipt No. - Permit No. Is uance D e Mailed Delivered-—�--y
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZELTON.AVE:,P.O.Box 2009 STOCKTON,CA 95201
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