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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication.
<br /> -0 APPLICATION
<br /> (For Non-Transferable,Revocable, end Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE n...
<br /> Application is hereby made to carry on business in the jurisdictional area of yg n oaquLocal Health District
<br /> FBusiness Name (DBA) s 'Addressl
<br /> Address~ a
<br /> Q Owner.
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> aG7`7 Emergency Telephone No...
<br /> a Business Telephone No. b
<br /> Contractor Licence No.
<br /> L Title Date r
<br /> L Applicants Name (Print) �-
<br /> Please check Applicable Category.(1-7)an Fill-in the Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �`' 4
<br /> For July 1,_June 30, 19 Disposal Sites - - - -
<br /> `Descrlpirpn(Make/Yr., Color) I
<br /> Serial No.{ CAL. License No. CAL. License Renewal No.
<br /> Capacity
<br /> •oG'a1 Weights e-MeasUre'S No's
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARIf '
<br /> For July 1, June 30, 19 t"
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> r 3. ❑ PERCOLATION TEST F F
<br /> r ' I = R.S.or R.C.E.No. r '
<br /> R.S. or R.C.E. Name _ z
<br /> " Test Date/Time t
<br /> Test cation t I
<br /> 4. SANITATION PERMIT 70
<br /> �Joli Addr ss/Location
<br /> Owner Address
<br /> * ..
<br /> D SEP''IC'TAV— ❑ CESSPOOL LEACHING FIELD .SEEPAGE PIT ❑ PACKAGE PLANT
<br /> '
<br /> ❑ OTFFER
<br /> ;,PERM1IhgNrNT*,> ❑ TEMPORARY, ❑ NEW REPAIR,
<br /> ❑ TOILETS For July h;-June 30,-19
<br /> t
<br /> S: CHEMICAL y i
<br /> ,' _ = �' r G Disposal Site
<br /> 7Y -
<br /> � Pe�or`tstruction - -
<br /> :No 71 l7niis' ' .. r'`Equipment Storage/Cleaning'Location(s) h;
<br /> 6. 13 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 e � �
<br /> Operator Namte When Certified-
<br /> Plant Location ' '
<br /> f" No. Units Served r
<br /> Plant Capacity ')
<br /> 7. ❑-L-AUNDRY, For�July 1, -`June 30,.19-
<br /> 51ZE:q, -
<br /> ❑ Less Than 1'000 Sq,Ft, s❑'More'Than 1,000 Sq. Ft.
<br /> .j Thar -1,000
<br /> ❑ DRY CLEANING,Cbemicals Used/Amount/Mgt
<br /> Flumeown@r-,,cq m;nce:si;'t^1vffrkfort,,,N , t1ii1permitisissued.lshalt not ernployany person
<br /> In such manner as to I)8t ;::: tl'�Ik l .� 'fi{i {�A5 n.lfoll t 3 ` '
<br /> Contractors hiring or sub <_ ..- 1.c..,, vertiflas tho fohl wins, i certify that in the pertormance 9t the tv4k tar which this.permit is issued,[-shalt
<br /> employpersons.&ubjeCt•to•Lo i:iawS•01•L ii ter ilia."
<br /> I hereby certify that -hpv repare this''application and that the work will be done in accordance with San Joaquin County
<br /> -•�
<br />� :ordinances, state laws,a � and'rlrgu 'ons of the Joaqui call alth District.
<br /> APPLICANT'Sa9r6igAtIURE ` �,. { '
<br /> a. `' `"c
<br /> 6R DEPARTMENT USE ONLY t a f
<br /> _5 6F L �
<br /> Pestis"DUB: ❑YANNUALLY~�❑ PER UNIT - c Pui TE ❑ EACH Cl Janulary4 &Receld By January 31 t ❑ July 1 &Received By July 31
<br /> REMIT-t4-
<br /> BASE EXPLANATION BILL"ING REMITTANCf� 1� AMOUNT DUE CHECKED) Y
<br /> DATE DATE F>. i REMITTE6_,,,,,�, r AMOUNT p
<br /> FEE }
<br /> n PRORATION'
<br /> i PLUS , • i �i �, _ _� r
<br /> w -PENALTY Y ,/ L".t !/•7 -G^ - ::.'
<br /> OTHER
<br /> I i
<br /> . OTHER - - -p--
<br /> ��_ _ ..•w..Y,., __r.. ..._ r _ v
<br /> '17\0
<br /> Received by - Date 'Receipt No. Permit No. Issuance Date ed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - '1601-E.HAZELTON AVE.,P.D.Bo=2009 STOCKTON,GA 95201
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