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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable, and Suspendabte) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is hereby made to carU Qn busR s in,.th jurisdictional area of t San Joaquin Local Hellth District
<br /> H Business Name (DBA) j �., C- ..V r— -Address
<br /> aOwner-i_E,E_=1 _WL ��•�. Address __..
<br /> J Firm Partners, Addresses a elephone Numbers 4
<br /> aBusiness Telephone No.. k. Emergency Telephone No.
<br /> Contractor Licence No. ~
<br /> Applicants,Name{Pring . Title ate
<br /> Please check Applicable Category (1-7)'and Fill in the Required Information. ,
<br /> 1. ❑ PUMPER,VEHICLE PERMIT REGISTRATION (FOR EACH IVEHICLE) 1
<br /> For July i, 'June 30, 19 - >
<br /> Disposal Sites N
<br /> Description(Make/Yr., Color) t�`� t x t , r Jr;
<br /> Serial No. CAL. License No.� CAL-. Lhcense Renewal No.
<br /> Capacity Gal.,Weights & Measures No.__ - -� -�""``-� ..
<br /> Equipment Parking Address �.�----" ,_,.r,... -
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19No. of Vehicles Stored"" 1.
<br /> i
<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 /> 1'Test Location _ Test Date/Time a
<br /> 4. ❑ SANITATION PER7IT E
<br /> aJob Address/Lo'ati n
<br /> O er Address _oe - ''_
<br /> EPTI 'TANK' f❑' CESSPOOL 1
<br /> t "LEACHING FIELD',: ❑ SEEPAGE PIT` ❑"PA'CKAGE'PLANT'
<br /> PERMANENT ❑ TEMPORARY NEW 1 ❑ "REPAIR ❑ OTHER
<br /> �5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 r
<br /> 1
<br /> Type Construction Disposal Site
<br /> No. of Units Equipment Storage/Cleaning Location(s)
<br /> ,6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> (Operator Name WhereiSertified—
<br /> Plant Location
<br /> r 11�l _ i ,.-:I.-t
<br />.. ,Plant Capacity No. Units Served I
<br /> y 1. ❑ LAUNDRY For July 1, -June 30, 19
<br /> ^- SIZE: 13Less Than 1,000 Sq. Ft., C1More Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r ^Y-� —� = I•- u
<br /> C � 3 {
<br /> I hereby certify' ve prepared this ) {' e
<br /> r I Y p p plicaEion i work will tie done in accordance with �an Joaquin County
<br /> ordinances,
<br /> St a laws, d r fes an r gu]Atii,ns, e S n J a uin Local ealth District. t
<br /> �,.,.. _
<br /> APPLICANT'S SIGNATURE X6.
<br /> J� t
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee Is Duel: ❑ ❑
<br /> ANNUALLY PER UNIT ❑ PER SITE ❑ EACH C1January 1 &Received By January 31 ❑ July 1 &Received By�J—uly 3i
<br /> 1,
<br /> - BASE EXPLANATION BILLING REMITTANCE $ REMIT
<br /> DATE, DATE -REMITTED '=AMOUNT DUE CHECKED
<br /> AMOUNT
<br /> � _•FEE-�r''�"',w..'s r.,��,a�,� _ ..v�w�r
<br /> LESS _ r r
<br /> PRORATION - 'f° f
<br /> PLUS 1
<br /> PENALTY
<br /> OTHER y -
<br /> OTHER
<br /> 14,
<br /> Received by"" In'Ej
<br /> Recdipr . Permit No. Issuance Date Mailed elivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 '
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