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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _tea
<br /> APPLICATION _
<br /> (For Non-Transferable;Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT ^' '��""
<br /> LIQUID WASTE
<br /> Application is hereby made a on busi Sint Di
<br /> l}e' risdictional area of the n. aquin Lo I H alt�i
<br /> �;Business Name {DBA) jC stri Address L,
<br /> a Owner ..
<br /> _ Address
<br /> Firm Partners, Addresses d elep-hone�Nu bers Y� "
<br /> aBusiness Telephone No. S Emergency Telephone No.
<br /> Contractor Licence No.
<br /> -
<br /> Ap;plicants fame{Print)�`� . .Title pate r D�
<br /> ..w Please check Applicable Category.(1-7)and fill.in the Required Information -- � -
<br /> _. z
<br /> 11. t `PUMPER yE�11CLE PERMIT,REGISTRATION (FOR EACH VEHICLE)
<br /> La✓For July 1, 1 Jue 30,n 19 •-- _ ('n
<br /> � ti —Disposal Sites
<br /> description(Make/Yr., Color) '. b.=_-y
<br /> Serial No
<br /> . y
<br /> CAL. License No? CA_
<br /> L. License Renewal No.
<br /> Capacity --- Gal.;-Weights-&-Measures•No:
<br /> Equipment Parking Address - --
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19a
<br /> No. of Vehicles Stored
<br /> No. of Chemical To _ilets Stored � ��'�`" `""r`—"""`�— �--^ ��•--�-- �....�.,___----,.�,,.
<br /> 3. 0 PERCOLATION TEST t
<br /> R,S.or R.C.E. Name's R.S. or R.C.E. No.
<br /> Test Location,J f_ Test Date/Time
<br /> 4. ❑ SANITATION PE 4
<br /> Job Address/Location
<br /> 4 3 r• s
<br /> Owner r 1. n.tAddloss
<br /> ^, - `
<br /> IF
<br /> ❑ ,SEPTIC TANK ❑ CESSPOOL LEACHfNG FIELD L s*i7 ItPAGE I'IT ❑ PACKAGE PLANT'
<br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWV
<br /> " REPAIR 13 OTHER
<br /> 5. ❑ CHEMICAL TOILETS For July 1,)e-June 30, 19 a i�
<br /> Type Construction J,� Disposal Site--,_--
<br /> No.of Units
<br /> Equipment Storage/CleaningiLocation(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, June 30, 19 ._t "
<br /> t
<br /> Operator Name i R _ . Where Certified
<br /> Plant Location j r
<br /> +J .r
<br /> Plant Capacity Nd.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."` � r
<br /> I hereby certify t f ave prepared h applicati and that the work will be done in accordance with San Joaquin County ^{! r t
<br /> ordinances, state laws, n I n e J uin Local Health District.
<br /> APPLICANT'S SIGNATUR
<br /> FOR.DEPARTMENT USE ONLY
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER;UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 N Rece#ved By July 31
<br /> BILLING REMITTANCE REMIT I
<br /> BASE EXPLANATION $
<br /> t HATE DATE EMITTED AMOUNT pUE yCHEGKED
<br /> AMOUNT
<br /> ;FEE ;SS
<br /> PRORATION 1
<br /> PLUS ,
<br /> PENALTY
<br /> OTHER
<br /> tr S
<br /> i £ _j
<br /> { OTHER
<br /> _Fr
<br /> ;......�.. ..f ...w- _ ,-,�.._......•.............min-....e.- -_,.-..... .w.-.. ...� ....�....-..., ,. ti�a �. ...r . -�.,r.,., -�.,,.�..,..!' J
<br /> d Received by Daie Recei t No.
<br /> P Permit No. Issuance Date Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES f0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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