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Applications Will 8e Processed When Submitted Properly Completed. Be Sure To Sign The pp ca,lon.I ,
<br /> APPLICATION '# "
<br /> �. Y i - s
<br /> (For Non-Transferable, Revocable,and Suspendable) ( SEPTAGE f i
<br /> (� ENVIRONMENTAL HEALTH PERMIT i
<br /> �' lJ LIQUID WASTE
<br /> cow-
<br /> Ap-plication is he eby made to carry on business in he'urisdictional area of the San Joaquin Local Health District
<br /> Address PM.��
<br /> Business Name (DBA) -
<br /> z Owner Address
<br /> a
<br /> Firm Partners, Addresses and Telephone
<br /> Numbers i
<br /> aBusiness-Telephone No. �� Emergency Telephone No: M
<br /> Contractor Licence No. lir Dale Z
<br /> L Applicants Name (Print) I � y Title ti— .
<br /> Please check Applicable Category (1-7) and Fill in the Required Information M:'-
<br /> 1.
<br /> :=1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, June 30, 19 Disposal Sites - r
<br /> Description(Make/Yr.,Color) CAL. License Renewal No.
<br /> Serial No. " """ ""�" CAL. License No. -
<br /> Capacity Gal., Weights & Measures No.
<br /> Equipment Parking Address - - -
<br /> 2. ❑ PUMPER YARD I
<br /> For July 1,_ 0June 30, 19 r
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored '
<br /> 3. ❑ PERCOLATION TEST i
<br /> t +
<br /> R.S. or R.C.E. Name R.S. or R.C.E. N0.,
<br /> Test Location Test Date/Time T
<br /> - ,�
<br /> 4. SANITATION PER
<br /> Jab Addres /Location z-
<br /> L,� Address !
<br /> Owner ❑ PACKAGE PLANT
<br /> t ❑ SEPTIC TANK 1 i ❑ CESSPOOL L€ACHING FIELD EEPAGE PIT
<br /> OPERMANENT ❑ TEMPORARY C3 NEW REPAIR ❑ OTHER f
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 `
<br /> Type Construction1 Disposal Site
<br /> 9
<br /> Equipment E ui Stora a/Cleanin Locations) '
<br /> No. of Units HS q p 9 „
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1
<br /> Operator.Name i4 Where Certified
<br /> �
<br /> Plant Location 1
<br /> Plant CapacityT �No:Units Served
<br /> 7. 11LAUNDRY For July 1, -June 30, 19 131 ( _
<br /> SIZE: Less Than 1,000 Sq. Ft., ©'Mo a Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEAN ING,'Chemicals Used/Amount/Mo.
<br /> lfit��tts#ailvwlsra;"Icertify'hat+ t'?^1e f,rma;,rea ta,e
<br /> ! prsn
<br /> scrkmdlshaye �
<br /> Home owner Dilicensed agent's 9n®tcFrecc,
<br /> , itisisse , s
<br /> in such manner as to become SuNect t0 ti'GTka u^R n:Jr 3C:Safi, ':-s PfifprRt -
<br /> Contractor's hiring of suh ccs trsntintl fig urtl r$..i'sex mksr fr;;tav�in t c?;lily t`aE:r Ilic perta,mance of the work for which this peratit is is sued.t shall
<br /> employ persurrs'subject to Workman's camp
<br /> ens8ttali 14ws of Califorlli,1' .
<br /> I hereby certify that I have epared this'application and that w k-will a done in accordance with San Joaquin County
<br /> ordinances, state laws, a r es nd regulation f the San aquin ocal He th District. `
<br /> APPLICANT'S SIGNATURE X ifs
<br /> f l
<br /> Y ...r. FOR DEPARTMENT USE ONLY
<br /> �
<br /> Fee Is Due: ❑ ANNUALLY El PER
<br /> PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31, ❑ July 1 &ReceivedREMITuly 31
<br /> s '
<br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED
<br /> BASE
<br /> _ . DATE. DATE REMITTED. AMOUNT
<br /> 00
<br /> t FEE P
<br /> LESS
<br /> PRORATION - r
<br /> PLUS } 1t 8
<br /> E PENALTY
<br /> .. OTHER ._ .,, -„ w.;-� # ,yr„�,,,- ,,.,,,;,a..,, -- ,,,,.. w•-� - �. ,.�.w... P .k .�..
<br /> OTHER . ; i g. >;. -► I'` .
<br /> Received by Date Receipt No. Permit No. Issuance to Mailed Delivered
<br /> }
<br /> ERVICES .1601 E.HAZELTON P.O.Box 2009 STOCKTON,CA 95201
<br /> APPLICANT—RETURN ALL COPIES TO:-_ ENVIRONMENTAL HEALTH PERMIT/S
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