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Applications Will Be Processed When Submitted ProperlyCompleted Besure 1o sign 1nexyN++�a.+.,++•
<br /> APPLICATION I fl�t.t
<br /> . s (For Non-Transferable, Revocable,-and 5uspendable) / SEPTAGF
<br /> - " ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE>
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<br /> Application is eby made to rry o mess in the tun Ictional area of�l an J quin Lo aIF
<br /> F Ith istri t
<br /> `:Address •fir` ,�
<br /> yBusiness Name (DBA) -
<br /> aOwners... - - Address
<br /> 2 Firm Partners, Addresses and Tel pne Numbers t "
<br /> a _Emergency Telephone No..,
<br /> a Business Telephone No.
<br /> Contractor Licence No. �y i "' /1 Z�
<br /> 1 I Date
<br /> LApplicants Name (Print} y �r Title y r
<br /> Please check Applicable Category (1-7),andYFiH�in_the Required Information tfi ez ^,fur¢ no rrf
<br /> 1. '❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1,--- — -June 30,,-19-��:-.-"-_'
<br /> Disposal.Sites
<br /> Description(Make/Yr., Color) M
<br /> x -• •--- --�-^� � ' CAL. License Renewal No.
<br /> Serial No, CAL. License No.
<br /> Capacity _ .,Weight
<br /> R Measures No.
<br /> Ca y GalWeiht1
<br /> P K 'E .
<br /> Equipment Parking Address
<br /> 2.11❑ PUMPER YARD Ia
<br /> For July 1, June 30, 19 `
<br /> No. of Vehicles Stored
<br /> ' No. of Chemical Toilets Stored
<br /> 3.1j❑ PERCOLATION TEST
<br /> ` R.S.or R.C.E. Name r R.S.or R.C.E. No.
<br /> Test L cation - ' # Test Date/Time
<br /> ;t�t
<br /> 4.1ySANITATION PERMIT
<br /> '
<br /> rr Job Address/Location L
<br /> O nerAddress
<br /> SEPTIC TANK ❑ CESSPOOL` LEACHING FIELD ❑ SEEPAGE-PIT ❑ PACKAGE PLANT r
<br /> I PERMANENT ❑,TEMPORARY 11 NEW 0'REPAIRL 11 OTHER
<br /> ..,.. , . -G, - {. ;
<br /> 5." CH .eEMICAL TOILETS For July 1, -June 34, 19 +.ai �� ce ML
<br /> Type Construction A Disposal Site,
<br /> No. of Units _. i�, � _Egoiipment Storage/Cleaning Location(§)
<br /> 6R ❑ PACKAGE TREATMENT!PLANT--,For July.1,-June 30, 1S
<br /> t 1• _-)s ' Where Certified
<br /> Operator Name -
<br /> Plant Location + h
<br /> ' No. Units Served
<br /> Plant Capacity t ,
<br /> 1 7 t❑ LAUNDRY.I For July 1, ,;June 30, 19--
<br /> SIZE- 13 Less Than 1,000 Sq. Ft.,. ❑ More Than 1,000 Sq. Ft. I
<br /> d DRY CLEANING, Chemicals Used/Amount/Mo.+
<br /> ( rN iaiiseoilhevw4rkfor whichthispermilisissu¢d,lshai=r,4terr+pl4yany prs4
<br /> ! ,I{ AtAIi1F'Atfi��ii�polp{(t?fil�n� liEitt�gs (lr ihnfeflwlr Icert{ty,M4,ir?;t1��e }
<br /> [}�CC 111A1ifl9f$`�I hPi pIS1Ptl(3�A (3 VvQ!'IS It ?a d67 of 1'�� Uit l2tiv �4 Ai 7(i ni3.`,
<br /> f+lriHg �r Via!#wrtrtrr3�ting�algnc4vrrk prlrtia� h*�€a5tlstivingl: "s eer;ii;r iilaF ir.the periarraarce ct t!1�:^aorr,fors;llich if;:;Ni-rl5kit is issued,I shat!
<br /> ? ! flfil f® (3i11Fi9h5 unlprmsatl9$lay.,'I
<br /> i 4 `s s
<br /> 1 I hereby certify that'l have prepared this application and that-the work will-be done in accordance with n d i County
<br /> it
<br /> ordinances,-State lavas, and rules and re I tions he San Joaquin Local Health District
<br /> APPLICANT'S SIGNATURE X
<br /> it
<br /> FOR DEPART.MENT.USE ONLY
<br /> 1. Fee IS Due: 13 ANNUALLY PER UNIT El PER SITE ❑ EACH+ ❑ January 1 &Received By January 31` ❑ July 1 &Received By JUIy 31
<br /> REMIT..
<br /> `
<br /> BASE EXPLANATION BILLING REMITTANCE
<br /> SAMOUNT DUE CHECKED
<br /> P S } -DATE � DATE � - REMITTED AMOUNT *'
<br /> FEE
<br /> LESSPRORATION
<br /> PLUS " - .. _
<br /> PENALTY
<br /> OTHER
<br /> OTHER ,r a
<br /> ! - - - ;Permit No. - >, Issuance Date Mailed Delivered
<br /> Received by Oate y ,Receipt No: ,
<br /> s s
<br /> APPLICANT-RETURN ALL GOPIES To."' ENVIRONMENTAL HEALTH PERMITISERYICES` `1601 E.HA2£LTON-AYE. P.O.Box 2049 ` STOCKTON,CA 95201
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