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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> ' — APPLICATION dI
<br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District
<br /> F Business Name (DBA)Ta.A.Ps4 Z��S� �ZQ� t A2C . Address ��•�XVL}-i -�t45;!5ZQ j
<br /> a Owner Address
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> CL
<br /> Business Telephone No. L"4""9(pCJ� Emergency Telephone No.
<br /> Contractor Licence No.
<br /> 343..
<br /> L Applicants Name (Print) 7z>1�_ _ _... Title Date. — I —
<br /> Please check Applicable Category (1-7)and fill-in the Required Information r
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1,= June 30, 19-
<br /> Disposal Sites -
<br /> Description(Make/Yr., Color)
<br /> Serial No. CAL. License No. CAL. License Renewal No.
<br /> Capacity ° Gal., Weights & Measures No.
<br /> Equipment Parking Address n
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, i{ June 30, 19
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored _
<br /> 3. ❑ PERCOLATION TEST r
<br /> R.S.or R.C.EfNVame R.S.or R.C.E. No. +
<br /> Test.Locationb tt Test Date/Time t
<br /> 4. 2SANI-kTION PERMIT r
<br /> f j(21 S L1 N�t_Ja
<br /> Job•Address/Locatio�nt
<br /> Owner Address
<br /> ❑ SEPTIC TANK ❑ CESSPOOL- a❑,L:EACHING FdELD r 0-SEEPAGE PIT- 13.eP.ACkAGE-PLANT
<br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR XOTHERAy,yq�
<br /> -5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19
<br /> Type Constructs`n Disposal Site
<br /> No. of Units Equipment Storage/Cleaning Location(s)
<br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ` `T
<br /> Op gator Name _ Where Certified" -
<br /> Plant Location + I
<br /> Plant Capacity, f 1 r� No. Units Served c ;
<br /> 7. ❑ LAUNDRY For July,1, -!June 30, 19' '
<br /> SIZE: ❑ Le1ss Than 1,000 Sq.. Ft., ❑ More Than 1,000 Sq. Ft.
<br /> ❑ DRY.CLEE1131NG, Chemicals Used/AmounVMo. -
<br /> 4
<br /> I heret y,,certify.t- to h e preparedis applica in and t the work Will be done in accordance with-,San Joaquin County
<br /> ordinances„state la a ulations th- ,S J q �Loal .Health District. s +
<br /> APPLICANT'S SIGNATURE I
<br /> i : �
<br /> 1. T
<br /> FOR-DEPARTMENT USE,ONLY -
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ JanuaryYd &Received By January 31. ❑ July 1 &Received By July 31
<br /> f REMIT
<br /> -BILLING REMITTANCE $ r
<br /> t BASE +EXPLANA710N AMOUNT DUE CHECKED
<br /> DATE DATE REMITTED
<br /> AMOUNT
<br /> FEEr_-
<br /> / i
<br /> LESS
<br /> PRORATION
<br /> f PLUS - , f r R
<br /> �. t ..
<br /> a PENALTY
<br /> V
<br /> OTHER
<br /> >! _,OTHER.r,...... _ �..,...,,......r,.�..,.,,.¢., - -s,.,r-`.'. - -"...'+,.,ice”.^"'..""•.'� v +�.. -,..�ra�•$::.,"W" -a_«. ......,5_:,.. _
<br /> - .�{. `r`^� _ Ek .,� xs'; _t 1• tel-l L. fY"�...'� _ ... ° ,?'' ':I r''r,f; ,
<br /> --Received by_,,,, _ Date "- Receipt W Permr�_o. _ Issuance Date —Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.'P.O.Box 2 STOCKTOfV,CA 95201
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