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<br /> APPLICATION
<br /> (For Non-Transterable,Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> ...
<br /> LIQUID WASTE
<br /> ocal Health Distract
<br /> Application is hereby made to carry on business in the jurisdictionalarea
<br /> of the San Joaquin L
<br /> rs�
<br /> t,-Business Name (DSA) Tb-67( 0 J!�i)T'L}1 r�:�rn}1 '1` ' �� jr i
<br /> owner--1L---7iC 'll .I�Z:rC]:'(' �'}• r Address
<br /> Emergency Telephone No..
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> Business Telephone No. 'r
<br /> U
<br /> Contractor Licence No. Title Ov. Date.�—
<br /> Applicants Name (Print) �'ol]�Y �v1 ZV_ 11
<br /> ry(1-7) and Fill In the Required Information
<br /> Please check Applicable Catego
<br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (DOpo EA
<br /> es VEHICLE)
<br /> For July 1, June 30, 19 -- "—
<br /> I
<br /> Description(Make/Yr.,Color) 'I GAL. License No. CAL. License Renewal Na.
<br /> '
<br /> Serial No. �J
<br /> Cal.,Weights &Measures No.
<br /> Capacity _.�—• - ,
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> .For July i, June 30, 19
<br /> l' No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> E .3, ❑ PERCOLATION TEST I♦ R.S. or R.C.E.No.` s
<br /> t
<br /> R.S.or R.C.E. Name , Test Date/Time
<br /> Test Location
<br /> 4, M SANITATION PERMIT I
<br /> 1()70 North 1-1:I.[111wa ,
<br /> Job Address/Location t ^ 1 On ;lr�7".�}Z t r 1
<br /> 1,c�l�ert r'1 C�1 rill .0 t', +Qdress ❑ PACKAGE PLANT
<br /> Owner CESSPOOL! LEACHING FIELD 13 SEEPAGE PIT
<br /> I �SEPTIG TANK � EMPORARY �NEW El REPAIR
<br /> 11 OTHER
<br /> XK'KERMANENT �
<br /> f 5. ❑ CHEMICAL TOILETS Far July 1, -June 30, 19
<br /> Disposal Site
<br /> Type Construction
<br /> I Equipment Storage/Cleaning Location(s)
<br /> No. of Units
<br /> g, ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, i9 Where Certified
<br /> Operator Name I
<br /> Plant Location No. Units Served
<br /> i Plant Capacity
<br /> I --
<br /> 7, ❑ LAUNDRY For July 1, -June 34,© More Than 1,000 Sq. Ft.
<br /> SIZE: ❑ Less Than 1,000 Sq: Fti,
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> f 6 Flnmenwn4rorlist:nspdnpent'ssiynnt;6i ,rortifio:thnfoll"tIrq:"1rr.r,1,x,91;tin111Priot i:r»arc:0`t 1? ;0lkforce`ticltlhi;Permit isisstcee,Ishalltrotempl0yany per."I
<br /> 111 5S1rb IIlrl;iner;�s 10 become 5r,t,;ect ln-i'ork!',:^."'S C�7;r:rn'!3atl!?!11[?t^! 81 ;i,iiD'rti:'
<br /> I nr r�:.,�,.'inr":h;"sil lf7 5 7^rlStl l:]SEUeti,1 511111
<br /> `�4
<br /> ContrBr;rer s hiring er sub-rontmctinrt GEC,.^.:!tram ncrlitirs tits. tnitQ4:ilYr, .i c,lily.i A:m t t'i.ttlacinrr'' '
<br /> entploy persar;s si l,iacl t0 5'+er r:l.;!i 5�6n1,eSi5 lb 1!1 IS19ti GI ;'.ti°J1 rli f
<br /> 1 hereby certify that I have r prep ed this application and that th'e w rk w' I be done in accordance with San Joaquin Count
<br /> ordinances, state laws,and re ions of the an Joa o Health District. }
<br /> i APPL,CANT'S SIGNATURE X
<br /> FOR DEPARTMENT USE ONLY
<br /> REMIT
<br /> r Fee Is Due: D ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 July 1 Received By July 31
<br /> BILLING REMITTANCE AMOUNT OUF- CHECKED
<br /> EASE # EXPLANATION DATE DATE REMITTE11 AMOUNT
<br /> 1
<br /> FEE 4560 ')(
<br /> r PRORATION
<br /> PLUS
<br /> PENALTY
<br /> OTHER {
<br /> r t t is
<br /> OTHER
<br /> Issuance Be Mailed Dalivere�e
<br /> ate Receipt No. Permit N0.
<br /> Rec ved y 1601 E.HAZELTON AYE..P.O.aoa 211r)9 STOCtcTON,CA 95
<br /> U31-
<br /> APPLI ANT—RETURN ALL.COPIES 7" ENVIRONMENTAL HEALTH PERMtTISERVICES
<br />
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