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ra Applications Will Be Processed"When Submitted Properly Completed. Be Sure To.Sign The Application.
<br /> APPLICATION
<br /> r (For Non-Transierable, Revocable,and Suspendabie) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> w LIQUID WASTE
<br /> A lication is he made to car on bu In sin.the-unsdictional area of than J quin Local I�alth District
<br /> ,F Business Name (DBA) � .67Address,' '©i OIC
<br /> a Owner.. _ Address
<br /> w
<br /> Firm Partners, Addresses and Telephone Numbegrs� r�
<br /> a Business Telephone No. -, � _! - Emergency Telephone No.
<br /> a , .,_"4 .,• ,:..,a _ .
<br /> I j Contractor Licence No.
<br /> —�
<br /> f L Title. Date. ��Applicants Name (Print) r��T. r y
<br /> Please check Applicable Category (1-7) and Fill in the Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) N
<br /> For July 1, June 30, 19 _._:.. Disposal Sites _
<br /> Description(Make/Yr., Color)
<br /> Serial No. CAL. License No. Y.�ii CAL. License Renewal No.
<br /> Capacity Gal., Weights & Measures No.
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARDr
<br /> For July 1, June 30, 19
<br /> No. of Vehicles Stored • .
<br /> No. of Chemical Toilets Stored-, 7 ,
<br /> 3. -❑ PERCOLATION TEST
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> F ,
<br /> Test Location Nest Date/Time
<br /> 4. ❑ SANITATION PERMIT"'
<br /> Job Addr s/ cati n -°
<br /> er w. + Address
<br /> EPTICT�ANK"�` ❑+ SSPODL lo- LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT
<br /> PERMANENT ❑TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER f t
<br /> I -5. ❑ CHEM ICALt TOILETS For;July 1,-June 30, 19
<br /> Type Construction- ''' i.. - € Disposal Site t
<br /> No. of Units , # Equipment Storage/Cleaning Location(s) h'•' �`� �"`' -
<br /> 6. ❑ PACKAGE TREATMENT PLANT Fo'r July:1,=-Juner30;19,
<br /> Operator Namef - Where,Ceriified ' tri ;
<br /> 1. � �. s� ► � � ,
<br /> Plant Location
<br /> Plant Capacity � ; � 1 Na Units Served
<br /> .7. -❑ LA-UNDRY 1For July 1, --June 30, 19*^ � y € s f
<br /> .;
<br /> SIZE: © Less Than 1 000 Sq. Ft.,, More Than 1
<br /> ❑ DRY CLEA�J�NG� Chemic ls,Used/Ampunt/MO r
<br /> II HO:!'tLlawr3Er0- -..rs ;9ag r..s ts,7utu- ceralf^ t',Q'folta ng. Ir�nl;yt� 'iiltiepsiformanca.oftheTaorVforV;h,'hthis permilisrssued,Isha,irot emFfoyany,, N"
<br /> f' - in S:i6t1 inc^.nitt'I ..�tC l3r:Gomc SIIi3jtL1 t:i S':J,K?.�.1:i.„n11.EEt.,at.pr I CP
<br /> Caatraetur'v h:rirxs�or-su►s=sontr�ctir.�+signa�:sre cet'tsf�s�a the €nslt64l1e,g: "I sar:ify t;:at i::tits l,�rferl a;c�� ih^.vvgrk fLruhich this permt i5 issueL.i shah
<br /> employ persans su 3;e�t tn.vrorkl Ian's cur ponsztiun lav?s of Ca!Jornia:'t.;�. -•-- ;
<br /> I hereby-certify:.that,l,have-prepared thWapptication and that the work will be done in accordance-with San-Joaquiri-County
<br /> ordinarices, state laws, and rules and reg lations gkrtille San Joaquin Local Health District. -
<br /> APPLICANT'S SIGNATURE X. .. FOR DEPARTMENT USE ONLY
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH []-Janua-ry 1 &Received By January 31. ❑ July 1 &Received By July 31
<br /> t ; REMIT -
<br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKER
<br /> i DATEDATE. r REMITTED f- AMOUNT
<br /> FEE
<br /> LESS
<br /> t PROBATION «^ . '""' .1.
<br /> ,
<br /> PLUS
<br /> PENALTY
<br /> OTHER - -. .. ........ .3 '.
<br /> OTHER
<br /> Received by Date Receipt No:- Permit No. isSu ce to Mailed Delivered
<br /> `"APPLICANT—RETURN ALL COPIES TO:--"ENVIRONMENTAL HEALTH PERMIT/SERVICES, 160t E.HA AVE;P.O.Boy 21109 -STOCKTON,CA 95201
<br /> * 14 L
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