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Applications Will Be Processed When Submitled Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendabte) SEPTAGE
<br /> 't ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is her by made to carry on business in the.jurisdictional area of the San Joaquin Local Health District .
<br /> yBusiness Name (DBA) .�. / L-� 1[ Address
<br /> �f
<br /> z Owner :P. Address
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> I
<br /> CL Business Telephone No. rl-- Emergency Telephone No.
<br /> a
<br /> Contractor Licence No.
<br /> Applicants Name (Prink) � 4-, Z, ,ZZ-_z� Title Date �� 42— ,�j
<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. ; -`F CAL. License No_� CAL. License Renewal No. ti; -
<br /> Capacity L Gal., Weights &Measure's No. - 5
<br /> 7j
<br /> Equipment Parking-Address {{
<br /> 2. ❑.,PUMPER YARD t 4 ", 9 r {
<br /> For July 1, "June 30, 19 err
<br /> No. of Vehicles•StoKed -`�"• ,w' r i
<br /> No, of Chemical Toilets Stored ,
<br /> 3. ❑ PERCOLATION TEST -w--- -•-•-- �--n- � --�-•- +
<br /> R.3-or R.C:E Noi.
<br /> R.S. or R.C.E. Name r
<br /> Test Location ~ "'' '�" �Test Date/Time _
<br /> 4. C3 SANITATION PERMIT _
<br /> Job Address/Location f
<br /> ner _ zo • ,s !i�`� - Address es='
<br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑,iSEEPAGE� IT PACKAGE PLANT , i
<br /> PERMANENT ❑ TEMPORARY NEW []'REPAIR a -,GFOTHER ,,�iZ )
<br /> 5. ❑ CHEMICAL TOILETS For Jul 1, -June 30, 19 _ ?
<br /> Type Construction y Disposal Situ
<br /> No. of Units Equipment Storage/Cleaning Location(s).'.,: ->
<br /> � , i s•,;�_ t ,
<br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 `^ a
<br /> Operator Name 3
<br /> . Where Certified- �-
<br /> Plant Location I tJ
<br /> Plant Capacity : No. Units Served t t f
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑(More1T,han•1;400 Sq- Ft
<br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> ref+
<br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County
<br /> ordinances, state laws, and rules and re lati of the an Joaquin Local Health district. y
<br /> APPLICANT'S SIGNATURE X
<br /> •P
<br /> FOR DEPARTMENT,USE ONLY
<br /> Fee Is Due:❑.ANNUALLY ❑ PER UNIT,__ _ ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By July 31
<br /> J BILLING $ REMIT:,,•
<br /> BREMITTANCE
<br /> BASE EXPLANATION ILLING DATE REMITTED AMOUNT DUE CHECKED
<br /> AMOUNT'
<br /> FEE S4S4j
<br /> LESS / /y
<br /> F
<br /> PRORATION
<br /> PLUS 1 u
<br /> PENALTY
<br /> OTHER
<br /> 4
<br /> 1 �
<br /> Received by - Date Receipt No. Permit No. - Issuancb Date Mailed Delivered
<br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.-,P.O.Box 2009 STOCKTON,CA 95201 },, .
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