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` —11V------Q----i nrrre ormocessea wnen submitted Property Cbmpleted. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> r (For Non-Transferable, Revocable,`and Suspendable)_ '
<br /> ENVIRONMENTAL HEALTH PERMIT , ` F SEPTA'GE-2,,`
<br /> LIQUID WASTE
<br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District
<br /> y Business Name (DBA) i
<br /> Address
<br /> Owner _ Address
<br /> UFirm Partners, Addresses and Telephone Numbers -
<br /> i
<br /> a Business Telephone No, Emergency Telephone No.
<br /> Contractor Licence No. r
<br /> Applicants Name (Print) Title
<br /> Applicable Category Date
<br /> Please check A
<br /> PP g ry{i-7}and Fill in the Required Information. _
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i
<br /> For July 1, June 30, 19 Disposal Sites
<br /> Description(Make/Yr., Color)
<br /> Serial No. f
<br /> CAL. License No. CAL. License Renewal No.
<br /> Capacity i Gal., Weights & Measures No. f t 1 1
<br /> t I
<br /> Equipment Parking Address
<br /> 2. El PUMPER YARD � •t.(. � _,,, �,,,.,� , �� �_
<br /> For July 1, June 311, 19
<br /> No. of Vehicles Stored
<br /> �' ✓ 1 f o n i t "�
<br /> No. of Chemical Toilets Stored L" -
<br /> 3. ❑ PERCOLATION TEST
<br /> i' .
<br /> R.S. or R.C.E. Name � )' ( Z.w.
<br /> a R.S. or R.C.E. No. r
<br /> Test Location i t Test Date/Time 1
<br /> 4. ❑ SANITATION PERMIT y .
<br /> Job Address/Location
<br /> Owner Address : ✓l
<br /> E] SEPTIC TANK 11 CESSPOOL ❑ LEACHING FIELD.If.•C] EEPAGE PIT ❑ PACKAGE PLANT
<br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW _ ❑ REPAIR ❑ OTHER
<br /> y
<br /> 5. ID CHEMICAL TOILETS'
<br /> r Ju
<br /> Fouly 1, -June 30, 19
<br /> Type Construction
<br /> Disposal Site .k, ! ''
<br /> No, of Units - ' Equipment Storage%Cleaning Locatibn'(sr
<br /> j.� i �,t I��
<br /> 6. ❑ PACKAGE TREATMENT LANT For July 1, -June'30, 19_ �,
<br /> Operator Name �,� Where Certified
<br /> Plant Location
<br /> Plant Capacity -•`No:-Units Served_.
<br /> 7. ❑ LAUNDRY For July 1, - une 30, 19 t
<br /> 141
<br /> n
<br /> SIZE: ❑ Less.Than 1,00.0 Sq1 Ft., ❑ More Than t;1.00Bq. Ft.
<br /> ❑ DRY CLEANING, Chemi Ials Ised/Amount/Mo. }
<br /> Homeasrvnerorricens dageFF�r,'sss'g ru:�c�r €fiesz a !i 3 I�r,tlt ,y tib, _:Ycr7tanc oiirr,anr ;�r-_ltichthisplrmit-silmed,IshzlfnotemplDyanypersDR
<br /> Ii2 Sl1Cit R1anREfn5 to t3eCDR1C hUtIJ2C1 L-
<br /> IX P e.G T',aP Suti�R (✓ Y """—�
<br /> t ,
<br /> Contractor's Hiring dr ,F3t-CCi1f qna LrC ettr E r �h;i,yply� ,J, li;y ilia',rlt tit.,pE;fOr>•iB�,C Dr tii6 4'SDr' for which this permit i5 issued,I Shall
<br /> employ persons subject tD wC"�ji�lclir�i iay.s u;Ca `
<br /> 1 hereby certify [hat I have prepared ths applicaton a d that the work will be done in accordance ithan:�oa —
<br /> ordinances, state laws,!and rules and regulations of thetan Joaquin Local Health District. gvin.Gourrtyl _—
<br /> APPLICANT'S SIGNATUR&
<br /> r. FOR DEPARTMENT USE ONLY 41.
<br /> Fee Is Due: ❑ ANNUALLY ❑ F?ER-UNIT ❑ PER$!TE ❑ EACH ❑ January 1 &Received.Bylianuary 31 ❑ July 1 S Received 8y July 31
<br /> REMITTANCE
<br /> KILLING REMIT
<br /> BASE I EXPLANA ION $ MOUNT DUE CHECKED
<br /> t t DATE DATE REMITTED
<br /> FEE I a' AMOUNT
<br /> LESS ;
<br /> PRORATION l
<br /> PLUS { r'
<br /> PENALTY ! l }
<br /> OTHER I t
<br /> I ,
<br /> OTHER
<br /> Received by -`- Date Receipt No. - PermitNo. Issuance Date M may— '
<br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '- ailed Delivered
<br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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