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Applications Will Be Processed When Submitted Proper y omp e
<br /> APPLICATION
<br /> f c' (Fofi Non-Transferable;Revocable,and Suspendabie) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT J - _�
<br /> f LIQUID WASTE / ' € T s `'t r
<br /> Application is hereby made to car on business in the jurisdictional area of'the San *uip SOXi;rLocal Qeal istrict
<br /> � ) -
<br /> r �9 F �.l5:7CAjC.° —Addresses
<br /> -t Business Name(DBA) Address
<br /> tZ
<br /> Owner
<br /> =4 and Telephone Numbers
<br /> Firm Partners, Addresses
<br /> J
<br /> Emergency Telephone No.
<br /> a Business"Telephone No. -
<br /> a 1�'w �►1 Z
<br /> Contractor Licence No. Date
<br /> _ •" Title
<br /># L Applicants Name (Print)
<br /> r Please check Applicable Category (1-7)and Fill in the Required Information ; . ;,•: h.;, ",- fn " s �
<br /> 1. Q PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For JUly 1 -June 30,'19_ , Disposal Sites' CAL.
<br /> A ,d License Renewal N -
<br /> Description-(MAke/Yr.,Calor o.
<br /> Serial No. ol
<br /> ' d`/ "'CALLicense Na' w. n
<br /> Gal.,Weights & Measures No.
<br /> Capacity
<br /> .; .t�-t--Mr
<br /> . Equip, el Part ing'Rddress
<br /> M ❑14UMPER YARD
<br /> Foy 1, 1 June 30, 19 A
<br /> 1 No. of Vehicles Stored
<br /> j No:of Chemical Toilets Stored
<br /> f 3 .,© PERCOLATION TEST _ v
<br /> :^ R_YS. or FI:C.E. No. '"_ •
<br /> R.S.or R.C.E. Name Test Date/Time
<br /> Te
<br /> 4 t Location t '
<br /> ANITATN PERMIT y
<br /> . ., , IO .r
<br /> Jo Address/Location S�
<br /> I Address
<br /> Owner EACHING FIELD SEEPAGE PIT 13 PACKAGE PLANT
<br /> '❑ SEPTIC TANKi 13CESSPOOLS P- r -- ""'-. ❑ OTHER
<br /> f (] TEMPORARY_ ❑ NEW REPAIR-
<br /> ERMANENT w °.r
<br /> .� ._.�.
<br /> ❑ CHEMICAL`TOILETS For July 1,-June 30, i9
<br /> { Disposal Site N'
<br /> l Type Construction"a ti
<br /> No. vl Units Equipment Storage/Cleaning Location(s)" s i # t v
<br /> ❑ PACKAGE TREATMENT PLANT ,For July 1, -June 30.19 „ � �' i ti
<br /> 6:; _ Where Certified
<br /> "Operator Name , , Y
<br /> Plant Location p No. Units Served .^ -
<br /> Punt Capacity”
<br /> € 7 ❑ LAUNDRY For July.11, -June 30, 19 P 9 a{
<br /> or, ❑More Than 1,000 Sq..Ft: " z
<br /> SIZE: 11 Less Than 1,000 Sq.Ft., ;
<br /> dSORY CLEANING, Chemicals Used/Amount/MO.
<br /> 'i H,ameaystr+ctrorlief9�tFGflarUrr.t'aaignaaf`rrc�fn7illi-0�thegaliov�r4np:;'ierrtifyth t ntileperfnr;nanr,,mt*evierklor.vlticlrih'sspermit isissuzri_f haiinafemployfiryperson
<br /> in such rriarfiler as In heeorns Suhjert 40 lvgrkfn•71i s Compel laws of Ga iln+';iii." +•
<br /> Contractor hlrir:rZ or eub•��ntreril'+r� ;;sir..+t �. certiiias tF.e tollnvving: '9 Ce�fify.Ellatin t;1e pi:rfGr��U Ce ;=5c rtoj k felhicl;ihs56�e 'it is:=cued,I Shall
<br /> f a enlplOy sivl ons 31djPci to wol 4-,014ensat'su,,, ,sof Caiiicrria." {
<br /> i
<br /> 1"ereby"certify that I have repared this application and that the work will be done±in accordance wit San Joaquin County f r
<br /> 1rdfnances, state laws, an regulati of the Sa o quin o alt istrict � _
<br /> APPLICANT'S'SIGNATURE.X
<br /> FOR DEPARTMENT USE ONLY
<br /> a"" 1
<br /> PER UNIT ❑ PER SITE,
<br /> Feels Due: ANNUALLY F
<br /> EACH 113 January 1 &Received By January 31 July 1 8 Received By July
<br /> 0 0 _ - t REMIT
<br /> y' -
<br /> —BILLING r REMITTANCE $ AMOUNT DUE ' CHECKED
<br /> EXPLANATION 'DATE REMITTED q °� AMOUNT
<br /> BASE DATE
<br /> d � ...., .�_.. __ - ..
<br /> .� . - s•
<br /> -FEE ,.. r'• �,- ,:...�.}
<br /> LESS ' r
<br /> PRORATION + , .� .� ,••
<br /> PLUS
<br /> PENALTY'
<br /> OTHER
<br /> OTHER - _:
<br /> Issuance Date Mailed Delivered
<br /> a Date Receipt No. Permit No. s CA 55201 -
<br /> Received by � 1501 E.HAZELTON AVE.,P.O.aiSx 2009 STOCKTON,
<br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM1T15ERVICE$
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