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Applications Will Be Processed When Submitted Properly
<br /> Compieieu
<br /> APPLICATION
<br /> SEPTAGE
<br /> (For Non-Transferable,Revocable,and Suspendabie)
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> �v
<br /> Application is hereby made to carry on business in the jurisdictionaA�tl eof$Sthe San Joaquirn Local Healkh,Distnc ,
<br /> h Business Name BA) Address
<br /> z
<br /> i Owner
<br /> Firm Partners, Add sses and Telephone Nu tiers Emergency Telephone No._
<br /> a Business Telephone No. ; t - 3
<br /> -, I v
<br /> Contractor Llcence No. 4 1 {-___Title
<br /> L Applicants Name (Print) , F
<br /> and.Fill in the Required Informatlon t� ,._ I ,;: r. ,� - ., ,;(., agzlb S .,t x- ,
<br /> Please check Applicable£ategory (.17-,)
<br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -
<br /> Sites '
<br /> June 30, 19-- -"'� -.--,.-.,Disposal-
<br /> For July t, -'_ �
<br /> Description(Make/Yr., Color) `CAL. License No. - CAL'. License Renewal NO.
<br /> ,... •�
<br /> i 'Serial No.
<br /> - Gal.,Weights &Measures No.
<br /> Capacity -
<br /> t - -
<br /> ! Equipment Parking Address
<br /> 2. ❑ PUMPER YARD r r
<br /> For July 1, June-30, 19
<br /> F
<br /> No. of Vehicles Stored � .t
<br /> -No. of Chemical Toilets Stored
<br /> I. �
<br /> 3, El PERCOLATION PERCOLATION TEST t R.S.or R.C.E. No.
<br /> . , -=r
<br /> E R.S. or R.C.E. Name s r Test Date/Time
<br /> Test cation _
<br /> 4. SANITATION PERMITS
<br /> Job Address/Location ------------
<br /> 4 Owner Y Uri Address ❑ PACKAGE PLANT
<br /> 120"SEPTIC TAN ❑ CESSPOOL- ' LEACHING.FIELD ❑=SEEPAGE P1T ❑ OTHER
<br /> r ❑ PERMANENT
<br /> 11 TEMPORARY "❑ NEW ❑ REPAIR
<br /> a 5. ❑ CHEMICAL!TOILETS For July 1,-June 30, 19
<br /> i Disposal Site ,
<br /> i Type Construction
<br /> (Equipment Storage/Cleaning Location(s)
<br /> No. of Units r k
<br /> 6. ❑ .PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified
<br /> Operator Name ---------------
<br /> S
<br /> Plant Location y ` No. Units Served k
<br /> Plant Capacity I
<br /> 7. 0 LAUNDRY For July 1, -June 30, 19'
<br /> SIZE: ❑ Less Than 1,000 Sq, Ft., 1 ❑ More Than 1,000 Sq. Ft.
<br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo t sial,net,Tploy
<br /> �
<br /> t !%- ,`Z."i".• °p f,Pri ii: � 7 I-L 1_ .rc:' .. -
<br /> (t .,jec;wrsrGriiC9n"31^�n,y ,firer 1r :t ,s �I 'IGISia: Gi4c,!il� i „ �3r !shall
<br /> ' i7 s!lcit mar,er as', ti cc r�su , ;3 ,lal, �,.,r
<br /> (;r risRCta%r's �tirinp ar 15,sJ er,rs4 s:t,n� sE;,rlatu;Y; crsrts,tes ys,., f+^l!nv��ai5- f -,erti'v that Ill i„e pertoi',—lite 6 the lv&:k for wlfth this ,Mit I5i55ULd,
<br /> - r' piUy pt:r5pf15 5ub}t;ct to Ylofkmafl�CUIi1tIFn5aii�11 fa11.5 Of Calitrlrlli3. r -
<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, a rules and regulations-of the San Joaquin;Local Health District. -�- f
<br /> APPLICANT'S SIGNATURE X
<br /> FOR DEPARTMENT USE ONLY
<br /> PER UNIT. 1:1PER SITE El EACH E3 January 1 &Received By January 31 ❑ July 1 &Received By July 31
<br /> Fee Is Due: ❑ ANNUALLY Elf REMIT
<br /> 'BILLING REMITTANCE $ AMOUNT DUE CHECKED
<br /> ,BASE EXPLANATION 1 DATE -'DATE REMITTED RMOUNT
<br /> FEE f
<br /> LESS
<br /> PRORATION
<br /> t PLUS e-�.,+:y� `Y,. - _F; �x- �`”. • "fit . ._. =F +s.:. _ ',.
<br /> PENALTY
<br /> OTHER -
<br /> . y
<br /> fK
<br /> _ OTHER -;:
<br /> } ; a Permit No Issuance Date xMailetl eli
<br /> t �•+ ate`' Receipt No. , - _ ., -
<br /> Feceived-by ,y;�.,• .. 1601 E.HAZELTON AVE.,P.O:Box 2099 STOCKTON:CA 95201 .J
<br /> t APPLICANTS''AETURN'ALL'COPIES TO: ENVIRONMENTAL HEALTH PEFI.MITISERVICES
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