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r� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> APPLICATION 1
<br /> f (For Non-Transferable, Revocable,and Suspendable) / SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT `
<br /> LIQUID WASTE
<br /> Application is h reby made to carryon business in the jurisdictional area of the San Joaquin Local Health District 1
<br /> Business Name (DBA) =� 'Address
<br /> aOwner _ Address
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> CL
<br /> Business Telephone No. �'�.- rj s' Emergency Telephone No... w
<br /> Contractor Licence No r
<br /> Applicants Name (Print) A , 4 Title ��d.� c���/ Dale
<br /> Please check Applicable Category (1-7)and Fill In the Required Int ormation._ I.
<br /> t. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 14
<br /> For July 1, June 30, 19 — .:Disposal Sites -- l
<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 _
<br /> 2. ❑ PUMPER,YIIRD-
<br /> a w
<br /> For Ju1y1,. June 30, 19 ,
<br /> No`"of Vehicles'Stored
<br /> .No. Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST- } y a }
<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/Location y _ +
<br /> Owner -max
<br /> 0js'_ t r '-"Address
<br /> O'SEPTIC TANK ❑ CESSPOOL t, LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT
<br /> ❑ PERMANENT ❑ TEMPORARY 1, ❑ NEW ❑ REPAIR © OTHER #
<br /> ., < ,
<br /> %Q5. ❑ CHEMICAL TOILETS ForJuly 1', -'.June 30, 19 } ;
<br /> Type Construction . Disposal Site I G•l
<br /> No.of Units Equipment Storage/Cleaning Location(s) t C
<br /> 6 ❑ PACKAGE TREATMENT PLANT",For July 1, -June 30, 19
<br /> Operator Name }• ) Where Certified -
<br /> Plant Location-
<br /> Plant Capacrty� r-. •_ rt No. Units Served t r
<br /> 7. 11LAU4DRY For July 1,"-June 30, 19-'s _._ A.
<br /> 1
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft',-, ❑ More Than 1,000 Sq. Ft.
<br /> ❑.DRY CLEANING,-Chemicals Used/Amount/Mo. _ R
<br /> h
<br /> I hereby certify'-,that I have prepared this application and thatT'the work will be done in accordance with San Joaquin County-,
<br /> ordinances, state-laws;and-rules•and-reg ations.of the San Joaquin Local Health District.
<br /> APPLICANT'S SIGNATURE,X
<br /> re
<br /> y FOR DEPARTMENT USE ONLY,
<br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑:EACH © January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31#
<br /> REMIT
<br /> '+ } _■ —4 t BILLING REMITTANCE $
<br /> i BASE %,.�,t.,,..E7(PLANA710N._y. AMOUNT DUE CHECKEp
<br /> DATE. DATE REMITTED AMOUNT
<br /> FEE �. fir•. .►stir- .-.,.--� ,; t
<br /> i
<br /> +*_ LESS_._.-_� .- . - .,..�-.�- ..._. - ..� .�, ..>,., -- -..----<w- ,...—.� —,....w-..--"--••,---...v. ..y...��.. ,..+,`..
<br /> PRORATION
<br /> PLUS _ - - _ T --« .�-•--'-�
<br /> PENALTY I
<br /> OTHER l r
<br /> EOPOTHER
<br /> Received by q Gate Receipt No. Permit No. I I suan e e Mailed Delivered
<br /> APPLICANT—RETURN ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVIGEs 1601 E.HAZELTON AVE:;P.O.Box 2009 STOCKTON,CA-95201
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