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Vii::✓r.,f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> r APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE C °I 0C
<br /> Application I er made carry n siness ire jurisdictional area of theS,af Joa yin L a Health District
<br /> ,,;Business Name (DBA) ?3 T6A. p,-rJ a� 3e-rIJI C•Q,, _Address- ,"1' 61� �C N VA-)ht P41
<br /> a Owner SfCL/e �ZSO�. -- Address 11319 PIONcQ r A-vC 0�n�1
<br /> Firm Partners, Addresses and lephone Npumbers
<br /> a. Business Telephone No. r Emergency Telephone No. 7 -
<br /> ' Contractor Licence No.
<br /> Applicants Name (Print) 1:211 ON Title _.®wN r r Date
<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_11.9 Disposal Sites
<br /> 5 Description(Make/YT., Color)_`
<br /> Serial No. CAL, License No. CAL. License Renewal NO. r
<br /> Capacity F � 1- Gal., Weights & Measures No.
<br /> Equipment Parking Address,.
<br /> 2. ❑ PUMPER YARD "`}
<br /> For July 1, June 30, 19 4 ,
<br /> No. of Vehicles Stored �+
<br /> No. of Chemical Toilets Stored t
<br /> _ s
<br /> TE
<br /> -_COLATTitSt
<br /> -
<br /> ❑`PER �IOIV
<br /> R.S. or R.C.E. Nerve a i _`• " R.S. or R.C.E. No. `"
<br /> Test Location Test Date/Time r ` t
<br /> 4. ❑ SANITATION PERAIIIT, —7-7
<br /> '
<br /> Job Address/ cation ' t. ��'
<br /> ( Owner o ri _� _� Address C r U t4Ltri ,
<br /> p ❑ SEPTIC TANK C1 CESSPOOL ' LEACHING FIELD,i D SEEPAGE PIT ❑ PACKAGE PANT `
<br /> ❑ PERMANENT 11 TEMPORARY Q NEW,. REPAIR ❑ OTHER)4I&,"RT L2vvC4► Li iN
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 V""fh
<br /> Type Construction Disposal Site
<br /> y No. of Units _Equipment Storage/Cleaning Lwcation(s),'
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 1 9 t �` a
<br /> Operator Name _ Where Certified n
<br /> Plant Location
<br /> Plant Capacity `�No. Units Served
<br /> 7. C3 LAUNDRY For July 1, -June 30, 19
<br /> L SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. '1401
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> ate# y � it
<br /> hereby certify that I have`pTepaAed-this application and that the work will-be done in aw&darice with-San Joaquin County �,
<br /> ordinances, state laws, and I s and re ulations of the San Joaquin Local Health District. , , """'"- t
<br /> APPLICANT'S SIGNATURE X �
<br /> 0 j �j.� ,
<br /> Wl AIN j7`1_
<br /> 3 _
<br /> FOR DEPARTMENT USE ONLY.
<br /> Fee Is Due:.L] ANNUALLY' ❑ PER UNIT ❑ PER SITE 1 ❑ EACH' ❑ January 1 &Received By,January 31 ❑ July 1 &Received By July 31
<br /> + BILLING REMITTANCE v $ ` REMIT
<br /> (.''13ASE-= - EXPLANATION PATE DATE REMITTEt? AMOUNT DUE CHECKED
<br /> ..w - AMOUNT
<br /> FEE
<br /> LESS
<br /> PRORATION_
<br /> e. PLUS
<br /> �- PENALTY
<br /> OTHER
<br /> 'OTHER -
<br /> . :.w 1 ,tf3S. �`5_o40 ,
<br /> Received by _ Date Receipt No. Permit No.? i -lssua. e, to Delivered
<br /> " APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH.PERMIT/SERVICES 1601 E.HAZELTON AVE. 09 STOCKTON,CA 95201
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