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<br /> 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 /> ti Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District„.
<br />-�;Business l mR DBA _ _ Address_
<br /> / _.
<br /> a Owner Address -
<br /> J Firm Partners;Addresses and Telephone Numbers
<br /> aBusiness Telephone'No.- Emergency Telephone No,. }
<br /> Contractor Licence No.
<br /> L Applicants Neme (Print) ��. ._ Title Date OC3
<br /> Please check Applicable Category (1-7)-and Fill in the Aequired'Information .
<br /> 1. ❑ PUMOER VEHICLE PERMIT REGISTRATION(FOR EACH-VEHICLE) ;
<br /> For July 1,` June 30,19 Disposal Sites
<br /> Description(Make/Yr., Color)
<br /> Serial No. F # € "' CAL. License No. s � � '_ �,'CAL. License Renewal No.. r-1
<br /> Capacity TT y Gal. Weights & Measures No.
<br /> Equipment Parking'Address �� }• .i" '� c �;
<br /> 2. ❑ PUMPER YARD ` t ► i;
<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"- r*A Test Date/Time
<br /> 4. F SANITATION PERM.T.
<br /> Job Addres tion
<br /> Owner _ dress
<br /> 11 SEPTIC TANK ID CESSPOOL LEACHING FIELD QSEEPAGE-PIT- ❑ PACKAGE PLANT
<br /> �.PERMANENT `❑ TEMPORARY— ❑ NEW - REPAI '❑ OTHER a ,d�+•�- ,.� . r_Q
<br /> S. ❑ CHEMICAL T&L-ETS- For July 1, -June 30, 19
<br /> ,Type Construction " .,,Disposal Site
<br /> No. of Units. `~-. Equipment StoraUii/Cleaning Locations)
<br /> 6. ❑.PACKA`GE TREATMENT PLANT~For.July 1, -June 30,-19
<br /> Operator'Name ~''� K,. - Where Certified
<br /> ` Yy ..
<br /> Plant Location -; :ki
<br /> Plant Capacity _'--'�No. Units Served
<br /> 7. ❑ LAUNDRY For July-1, -June 30,19• .T.
<br /> SIZE: ❑ Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq. Ft, ;
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.. i '• '` r" '''
<br /> FJarrteowngrarlic�e-aed>lgatst'sRign�atureeertFfipsttsa>fcRcwmst� 1cFrtlfyth2fin'Ileperformanceeffhevrarlcfvrwhicfith's permit is lss�sed,IshallnotEmpioyanyperso.
<br /> t 111 su I"'71"Mof i25 to i6coniti Sli:lj�i t iP r 0 r-1Sa?'. l•'-ii, rl i
<br /> Cm-1-Ft_t01 s xi C'+ or S'_!t`-CCs -r3 r,}-, - - I { A
<br /> -+ - '_I 1t..F�;;: 1 Ct'-fil1�,Idi If]`:i•, -,i�y;l,; :i the.���I"for S h1C:`E liii5 S 8?"fl'::�S ISSJ6(3,I s1�a11 ^
<br /> Ei':p:.y p£,s�7rl +i;.;uU 1u 'olkri e,rS e.v:11N�i_-.I,.,.c i..,-:� f -
<br /> I hereby certify that I have prepared thi's application and that the work will be dohe i`n accordance with San.Joaquin County
<br /> ordinances, state1 andpos anq regulatio f the San Joaquin Local Health District. { #
<br /> j
<br /> AP=LI.CANT'S SIGNATtI E X
<br /> , £
<br /> 0141
<br /> f� FOR DEPARTMENT USE ONLY °t.
<br /> t
<br /> Fee Is Due: 1-1ANNUALLY. ElPER UNIT ElPER SITE 1:1 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31
<br /> REMIT
<br /> BILLING'" 'ry REMITTANCE $
<br /> BASE EXPLANATION AMOUNT DUE CHECKED
<br /> - t. - ,,-DATE PATE - REMITTED AMOUNT
<br /> FEE -/ f i '" `f �O
<br /> r
<br /> i LESS a; 4 J
<br /> G PRORATION
<br /> PLUS
<br /> PENALTY
<br /> { OTHER f
<br /> OTHER
<br /> 1 9-
<br /> Received.6y- --.,.w. :..�--�.Date_.:_ _ -„ .;Receipt No ,.Permit No- Issuance Date Mailed #Deliver_ed _
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTALHEALTH PERMITISFRVICES 1601 E`HAZELTON AVE.,P.O.Sam 2009- STOCKTON,CA 95201��
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