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Applications W111 Ise rrocessaa Tune..�.............. .._r- , --
<br /> APPLICATION' 'J
<br /> (Por Non Transferable,Revocable,and SuWndable) / SEPTAGE
<br /> 46 ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is heieby made to carry on business in the jurisdictional area of the 5ary19aq�uin Local Health District
<br /> Address
<br /> Business Name (DBA) 14
<br /> _y.Address �, O
<br /> i Owner 1, - -
<br /> Firm Partners,Addresses and Telephone Numbers ..Emergency Telephone No.
<br /> iBusiness Telephone No..— - _
<br /> 1 Contractor Licence No. `Title Date
<br /> < Applicants Name(Print)- C
<br /> Please check Applicable Category(1-7)and Fill In the Required.Inforrns#on
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE)
<br /> For July 1, June 30, 19 =- - - Disposal Sites
<br /> Description(Make/Yr.,Color) --
<br /> CAL. License No. CAL.Uoerise Renewal-No.-:=
<br /> Serial No. -
<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•Storetl-"
<br /> i - ......... T
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST 1 R.S, or R.C.E.No. —
<br /> R.S.or R.C.E. Name -
<br /> o°?��I' / ✓` Test Date/Time_-
<br /> Test soca � � '
<br /> 4. ANITATION PERMIT.
<br /> Job Address/Location �/ %/?,�G ---
<br /> Owner Address 0 PACKAGE PLANT ) fv
<br /> ❑ SEPTIC TAN K�❑ CES9`POOL'r - ❑ LEACHING FIELD ❑ SEEPAGE PIT 11 OTHER F
<br /> 11PERMANI=NT TEMPORARY 11NE_W ❑ AEPA1R +
<br /> ,
<br /> � i
<br /> 5, ,HEMMIICAL TOWELS For July 1,-June 30, 19
<br /> Type Consirvction� -_-Disposal Site -
<br /> Equipment Storage/Cleaning Locations)-
<br /> No�>Sf Units '�:• : .-,, 'r�--.�- _-�-
<br /> /6 ❑,PACKAGE TREATMENT PLANT For July1, -June 30, 19 {
<br /> I Where Certified— —{
<br /> /O>�ator Name - - - v,. - , .4 ► - -�
<br /> ,-" .Plant Location
<br /> -No.Units Served
<br /> Plant Capacity
<br /> �-^ - -� 1
<br /> 7. Y LAUNDRY For July 1;-June 30, 19_. - � +-*. - , N )
<br /> SIZE: Less Than 1,000 Sq. Ft., ❑ More Than 1,000q. Ft.
<br /> 13 r�
<br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. to I
<br /> — -
<br /> 1 hereby certify that 1 have prepared this applic to Io ego hat-the work will be done in accordance with San Joaquin County
<br /> ordinances, state laws,and rules and re atio of theSan Joaquin Local Health District.
<br /> 1 AP4
<br /> APPLICANT'S SIGNATURE X
<br /> FOR DEPARTMENT USE.DNLY_.•..,. L--- I
<br /> 1. Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 d Received ay Jen.,ary 31 El 1 8•Rec:eiv RBy
<br /> yITuly 31
<br /> — T CHECKED
<br /> _.,.�..._�--•------ �-''' �`r"Bll LINO REMITTANCE _•— AMOUNT DUE
<br /> I EASE EXPI ANATION ; DATE .DATE REMITdFD.��- •`,�,{ - , >( AMOUNT
<br /> 1
<br /> FEE
<br /> i
<br /> LESS
<br /> PRORATION - I
<br /> t
<br /> Pi�JS
<br /> t PENALTY
<br /> OTHER
<br /> OTHER -- - •----+'-�', ' .��:-
<br /> ---4 �--- .— J-J.iu D te•" Z,-,ied Delivered ,
<br /> Date - ReCeipl NO. Perm N 1
<br /> Received by 1601 E.HAZELTON AVE.,P,D.Eox 2009 STOCKTON,CA 0.5201
<br /> APPLICANT—RETURN ALL COPIES TOS ENVIRONMENTAL HEALTH PERMITrSERVICES_ _
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