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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheAppucauon.
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable;and Suspendable) SEPTAGE /
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application ereby mad(ho carryAn business in the jurisdictional area of thea an Jo uin Local Health Di rlct, I
<br /> cn Business Name (DBA) Et' + " Address,► ,
<br /> z Owner. Address
<br /> 9 Firm Partners, Addresses and Telephone Numbbeers -
<br /> a. Business Telephone No. 6 <�� Emergency Telephone No.
<br /> �Contractor Licence No. . q
<br /> L Applicants Name (Print) J" O _ Tltle 4'�S M Date
<br /> _ (1�r
<br /> ' Please check Applicable Category (1-7)and Fill in the Required rintormation
<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. J
<br /> Capacity i 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 p
<br /> 3. ❑ PERCOLATION TEST i ?
<br /> R.S. or R.C.E. Name ) R.S. or R.C.E. No. Y
<br /> Test ovation r Test Date/Time
<br /> l 4. SANITATION PERMIT
<br /> Job Addre s/�ocat" n - .
<br /> Owner < i Address +F°
<br /> SEPTIC TANK ❑ "CESSPOOL LEACHING FIELD ❑-SEEPA�GERIT
<br /> ❑ PACKA E PLANT °S
<br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAID 1:1 OTHER
<br /> 5. ❑ CHEMICAL'TOILETS For July 1, -June30 19 - i
<br /> Type Construction Disposal Site '
<br /> No. of Units Equipment.Storage/Cleaning„Location(s) }'
<br /> S A” tf 3
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1;, -June 30, 19 f
<br /> Operator Name - - '_ -- WhOlp Certified
<br /> Plant Location _
<br /> Plant Capacity f ?_ o;
<br /> Li—
<br /> 7. ❑ LAUNDRY For July 1, -June 30,
<br /> :SIZE: ❑ Less Than 1,000 Sq� Ft., ❑ More Than 1,0 SgV Ft
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo
<br /> Homeownerorlirsnsetl2 er+4ls >1 r �,rcrer€:s'I,�t+�rsallati l .P . t ,' oaf !mf!)rr1aJC,4cftri`�vc' fnr,.tit!ithlhispermitisisstsetl,lsirallno cia;.:cyantp ;ro?
<br /> CSULfI man:?Er a5 te,i)CCOT C 5l#i (ri'p ? r;;i l:S:5.it E iShc v S r r t" 'u k ` 4 s '
<br /> �ORtracto.'s hiring or �i;7-�4rt,�,,.r:r, �:;�;aic:c c:�::i':`c; ...: -C'� �.I:a:' �I CCi�,I(+ }t'e::1n il} _ s,�;'� �4�f�ti1C 4Ypii(far VJ�iliil 111+_;1,,,ifi a I Sil-���I Shall
<br /> employ peiS4 ks Sl bjc'Gf?J VlD fiiilan'S GGn7i f ISSiitr:r:',r6i Ca ,ra. 1� l�" <�–
<br /> I I
<br /> hereby certify that 'have prepared this application and that thet"'w''ork:wifl'be done"in accordance with San Joaquin County
<br /> ordinances, state laws, and rules and reg lations the S n Joaquin Local Health District.
<br /> APPLICANT'S SIGNATURE X
<br /> '11
<br /> FOR DEPARTMENT-USE ONLY--,�T----_W,.._..
<br /> Fee IS Due: ❑ ANNUALLY !' ❑ PER UNIT" ❑ PER SITE © EACH, ❑ January 1 &Received By January 31" ❑ July 1 8 Received By July 31
<br /> . REMIT
<br /> ? BILLING REMITTANCE $ AMOUNT DUE CHECKED
<br /> BASE EXPLANATION
<br /> DATE- t DATES REMITTED-. - AMOUNT'
<br /> FEELESS
<br /> PRORATION # E_
<br /> PLUS
<br /> PENALTY
<br /> OTHER I'i�-,..,may-- ...,...,.� .........�..»,. _ ..1.........:s..v �.i..:_�.r...-...,.. _ _ �..�.Y... -
<br /> `- OTHER , _ _ ice ; %^.F s i_ t
<br /> " - 1 x•:13 3 1- �..:- .
<br /> Received by 2 Date Receipt No. Permit No. Issuance ate Mailed elivered
<br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES -1801 E.HAZEL P .Box 2008 "RTOCKTON,CA 95201,-
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