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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application i rePy ma to carry on b ess in the jurisdictional area of the San Joaquin Locai�F�ealth Distri t
<br /> H Business Na e (PBA) �RJS i r Address 8S .$' !/ez 1/Pr✓ .S �c��Q„1
<br /> QOwner H, .5 Address Z,23�S �' �e-n1 >~�J S�1C eon3 /,�
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> a Business Telephone No. $^ 7d�
<br /> a epone Emergency Telephone No. F3 -7e,? G
<br /> 3 Contractor Licence No.
<br /> �Applicants Name (Print) Title e F- Date ^ F2
<br /> Please check Applicable Category(1-7)and Fill in the Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, June 30, 19 Disposal Sites
<br /> Description(Make/Yr., Color) �J
<br /> Serial No. CAL. License No. CAL. License Renewal No. O
<br /> Capacity Gal., Weights &Measures No.
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, _ June 30, 19
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No. `
<br /> Test Location Test Date/Time (`
<br /> 4. ?� SANITATION PERMIT
<br /> Job Address/L ation 95-- _S—
<br /> Owner
<br /> SOwner )AJ-S Address
<br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD .SEEPAGEIT- ❑ PACKAGE PLANT
<br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER
<br /> 5. 11CHEMICAL TOILETS For July 1, -June 30, 19 56 4
<br /> Type Construction Disposal Site -
<br /> No. of Units Equipment Storage/Cleaning Locations
<br /> 6. ❑ PACKAGE TREATMENT PLANT 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, -June 30, 19—
<br /> SIZE:
<br /> 0, 19 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> Home oumerorlieensedagznx's;ignF4;merar'iiie=+t,atolr�„r.n "!Ceiit; 1„tintheperformanceefthework fofiwhichthis permitisissued,Isilatlnot employ any perscn
<br /> it such manner as!a hea l^5 'i t t
<br /> Contractor'ssrii:;� 4wSQL'Cris'.-?,:;;�r. 5�- - .xiu�.ir�. -,fiE;��it):ilial ill:he pef'i.,',lance of the wort,for vjhich ti!i5 permit is issued,I shall
<br /> employ persons sui�jec”i,:v,Grr:rr,....s c•;np��._,..,,,,.w..�,,:[:�:,.:u, ..u. .
<br /> I hereby certify that I have prepared this application that the work will be done in accordance with San Joaquin County
<br /> ordinances, state laws, and.,"s d regulations of a San aquin Local Health District.
<br /> APPLICANT'S SIGNATURE..
<br /> I
<br /> i
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Q July 1 &Received By July 31
<br /> BILLING REMITTANCE $ REMIT - --
<br /> BASE EXPLANATION AMOUNT DUE CHECKED
<br /> DATE / DATE REMITTED AMOUNT
<br /> FEE
<br /> LESS
<br /> PRORATIONPLUS
<br /> /
<br /> PENALTY
<br /> OTHER
<br /> OTHER
<br /> I 86-
<br /> Received by I Date Receipt No. Permit No, Issuance DaV. .0.
<br /> ailed D Ii ed
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZE
<br /> ox 2009 5 GKTON,CA 952101
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