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i Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application t
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE
<br /> .� ENVIRONMENTAL HEALTH_ PERMIT
<br /> LIQUID WASTE
<br /> Appl ica ' is hereby made to car oy�bu ss in h "uri fictional area of trkte,SagJoa in Local Health District r
<br /> yBusin ame (DBA Address =
<br /> z Own Address SL
<br /> a -
<br /> Firm Partners, Addresses and Telephon Num ers -
<br /> aBusiness Telephone No. b p Emergency Telephone No.
<br /> Contractor Licence No. ZZ. !
<br /> LApplicants Name (Print) Title Date
<br /> -Please check Applicable Caleg (1'-7)and.Fill in the R uired lnformation r;
<br /> ❑ PUMPER-VEHiCLE,PERMIT REGISTRATION (FOR EACH VEHICLE) r
<br /> For'July-1; June 30; 19 _ Disposal Sites
<br /> Description-(Make/Yr';-,Color}''"t 4ti.r y
<br /> erial.No: C-2 CAL. License No. CAL. License Renewal No.
<br /> Ca acit "'4 ".Gal., Weights &Measures No.
<br /> �tEquipment Parking Address' !
<br /> I
<br /> 2. E] PUMPER YARD 0 - i
<br /> For July 1, _" Jurye 30, 19 _
<br /> No. of Vehicles Stored , ;
<br /> No. of Chemical Toilets Stored ` }
<br /> a �
<br /> 3. ❑ PERCOLATION TEST �
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> est Date/Time I
<br /> Test�Lo/cation f, I t b i
<br /> 4. L'1 SANITATION PER T,)� i
<br /> If
<br /> Job Add re s/Location
<br /> O�,w/ner u!� Address x j
<br /> I� SEPTIC TANK [J~CE POOL,. ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAG L NTS
<br /> LIPERMANEINT [:~TEMPORARY .0❑ NEWy�"=
<br /> 5. 13 CHEMICAL TOILETS For July i;r--June 30, 19` aD
<br /> Type Construction `�" t U¢ '' ` ear Disposal Site
<br /> No. of Units ° i Equipment.Storage/Cleaning L86tiori(s) t �y
<br /> 6. ❑ PACKAGE TREATMENT PLANT Fol•-July-1, "`-June 30, 19 t
<br /> 4 `"`�'L i Where Certified t
<br /> Operator Name yW" v
<br /> Plant Location
<br /> No. Units-Served
<br /> Plant Capacity
<br /> 7. ❑ LAUNDRY For-JUly1, -June 30, 19
<br /> SIZE: ❑ Less Than 000 Sq!Ft., ❑ More Than11,190 sorFt. '
<br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. � Y. _ ,
<br /> liemaowner orficensad agent's signature certifioathe foltoviring:"I certilyth Pit in the performance of the work for which this permit is issued,f shall not emtloyany person J>
<br /> in such manner as to becmne subj6%1 to wofkn,am c.car,pensafirm iiw,�
<br /> Contractov'•, IAring at st,h-eorttra;Vngs=�riszs=rs cert:+e< ( t7e .: i•sr„?, �`;,i...Filo pericr:;:aH_'^o',il;c,, for whi h-E;lir;sermit is issued,I shall
<br /> - g-'.':�'J�.•iJ"rSG.S_.,:;biC�t i� �'..-- �,,,,..i�•"s"3:.�F...�Y!::„:._ti...., _ I � ��.
<br /> hereby certify that I have prepared this application and that the work will be done in accordance with San`Joalauin County
<br /> - ordinances;'state laws, a d rules and re ulati ns of the San Joaquin Local Health District. .
<br /> APPLICANT'S#SIGNATURE X ,
<br /> -r ....,.-.F. ..,,.,.. rrf``J.�i
<br /> r i t •q S. FOWDEPARTMENT USE ONLY
<br /> ��
<br /> Fee IS DUe: ❑-ANNUALLY ❑ PER UN1T`!� PER SIT ❑ EACH- ❑ January 1 &Received By January 31 ❑ July 1 8 Rece�Yed By July 31
<br /> __-_._.....-_ w... ---c-� _- "- y 1 REMIT
<br /> y - JAR J $ASE } EXPLANATIONS ' BILLING REMITTANCE , i $ �2 4 'AMOUNT DUE CHECKED
<br /> r� DATE DATE REMITTED`-°�i �` ` j t' rgMOUNT
<br /> FEE '' ..... -.�..•f t
<br /> LESS! I _` Y, ..'.'r-':.r..i'^-ti. '•
<br /> PRORAtION
<br /> j� v - 10.
<br /> PENALTY , - - r
<br /> OTHER
<br /> f OTHER
<br /> Received by Da a ,-. Receipt No. Permit No.
<br /> issuance,Date Mailed - - Delivered
<br /> APPLICANT—RETURN-ACL COMES TO:r-TO: - •--��"-4691'E:'HAZELTON'"AYE.,'P.O.•8nr-2009” STOCKTON,CA 95201
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