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Applications Will Be,Processed When Submitted Properly Completed. Be Sure To Sign The Application:
<br /> F, 4 i R06CATION
<br /> �`. (For Non-Transferable;-,Revocable, and Suspendable)
<br /> �a. ENVIRONMENTAL HEALTH PERMIT SEPTAGE
<br /> r ' - LIQUID WASTE
<br /> Application is hereby rhade to carry on business in the jurisdictional area of the San Joaquin Local Health District
<br />,n Business,Name (DBA) .Q,_�.d� �{ f� Address 4 �f �" k
<br /> aOwner-.`ter A Address
<br /> J Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No. ` Emergency Telephone No.
<br /> Contractor Licence No. i.s
<br /> 49
<br /> Applicants Name (Print) Title Date
<br /> Please check Applicable Category (1-7) and Fill in the Required Information Q -
<br /> 1., ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, June 30, 19 I' Disposal Sites
<br /> Description(Make/Yr., Color) I
<br /> Serial No. CAL. License No. CAL. License Renewal No.
<br /> Capacity Gal.,Weights 8� Meas Gres No.
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 1.9• - 1
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> 3..:❑ PERCOLATION TEST i
<br /> R.S. or R.C.E. Name r= R.S.'or R.C.E. No.
<br /> Test Location _- Test Date/Time
<br /> 4. ❑ SANITATION PERMIT - -
<br /> Job Address/Location i
<br /> Own T ` s" Address
<br /> f EPTIC TANK ❑ CESSPO.OL `"; EACHING FIELD ❑ SEEPAGE PIT`# ❑I'PACKAGE--PLANT-_ �t
<br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWz=.-'-'% ❑ REPAIR ` ❑ OTHER y
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 36, 19 !
<br /> Type Construction ^� _ Y ` *a Disposal Site •-`_-- "�=_ #
<br /> No. of Units _ Equipment Storage/Cleaning Location(s)
<br /> .6. ❑ PACKAGE TREATMENT-PLANT For July 1,-June 30, 19
<br /> �- f
<br /> Operator-Name T "- 1 - rtlfl
<br /> V&re Ceed F
<br /> Plant Location ---
<br /> Plant Capacity - No. Units Served
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,! ❑ More Than.1,000 Sq!Ft?-
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo._ -. 9
<br /> hereby certify that I 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 la i of the,S n Joaquin Local Health District.
<br /> AP.PLICANT's SIGNATURE X" �=L �`/ -
<br /> FOR DEPARTMENT,USE ONLY e
<br /> ) a
<br /> Fee Is,Due: ❑ ANNUALLY ❑ PER UNIT P.PER SITE ❑ EACH- ,❑_Janva(y I-&Received-By.4nuary_31 0-July 1 &ReceivedBy July 31
<br /> •
<br /> REMIT
<br /> • BILLING REMITTANCE $, -
<br /> „BASE,:,,,,,,,,, _,.EXPLANATION ___DATE TE REMITTED AMOUNT DUE CHECKED AMOUNT
<br /> FEE 5, QQ 91R
<br /> LESS
<br /> PRORATION
<br /> • 1
<br /> PLUS
<br /> PENALTY
<br /> OTHER
<br /> OTHER •` ' `-'1' ."�' . ;'..'�s "� - is
<br /> i
<br /> ra'vC
<br /> -79 `91x179
<br /> Received by Date - Receipt No. Permit No. Issuance Date Mailed .Delivered..
<br /> APPLICANT—RETURN ALL COPIES,1Tb: ' ENVIRONMENTAL HEALTH PERMIT/SERVICES '- - 1901 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,6A'95201/^��� i
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