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APPLICATION
<br /> For Non-Transferable,Revocable, and Suspendl '! SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District
<br /> Business Name (OSA) Address +
<br /> Owner�rc Id 1 '� �1 n e ��ti�k1s�7-.SD-i1—
<br /> Address rig. S.• ri � 23. . PrAQS co S1>ac
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> Business Telephone No. Emergency Telephone No.
<br /> Contractor Licence No. n
<br /> Applicants Name (Print) Title Date
<br /> - S
<br /> Please,check Applicable.Category(1-7) and Fill In.fhe Required Information
<br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, June 30, 19 Disposal Sites
<br /> r—
<br /> Description(Make/Yr.,Color)
<br /> Serial No. CAL. License No. CAL.License Renewal No.
<br /> Capacity Gal.,Weights S 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 6
<br /> 3. ❑ PERCOLATION TEST J
<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 Add ress/Loca[ion �4P�— �'• 'StW-0n'*1'� 0
<br /> Owner i\Mh Q N1 `� L�t rimed^ Address , b Lnn� Sca 12x� S l r, Cc
<br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD a SEEPAGE PIT 0 PACKAGE PLANT
<br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19
<br /> Type Construction Disposal Site
<br /> No, of Units Equipment Storage/Cleaning Location(s)
<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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Fl.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> Horne ownrlrovtic tin d;sdagent'sdgrawrr^/•,-tO,.: '',J: lu ,:,,;;:"l ,r,;tyll.lin Me perimrmanerr;flhr.v:crpfcrra;icilWspermit isissund,Ishrlll,otempinyanyperson
<br /> in such manner.rc l6 f�cr:rrac sut.;�C':lu:7,a,'C 4,!'(:,
<br /> cc.
<br /> Contrr.rtu•'s hlrin.1 or aura-er nirar.tinu sSynan:rn certit,as tim talfowing: "I eel lily that In Ilse perfurmanee of the wnr ar which lilis permit is issued,I shall
<br /> employ persons sublerl to workman's r,.^,mpcosalion.laws UI Galik,'mia.-'
<br /> I hereby certify that I have prepared this application and that the work will be done in accordanee I with San Joaquin County
<br /> ordinances, state laws, and rules and regul of the Sawn Joaquin Local Health District.
<br /> APPLICANT'S SIGNATURE X �Jr 16 —2S _P71
<br /> FOR DEPARTMENT USE ONLY ,
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January t&Received By January 31 ❑ July 1 &Received By Jury 31
<br /> REMIT
<br /> BILLING REMITTANCE $ AMOUNT DU CHECKED.
<br /> BASE EXPLANATION DATE DATE REMAMOUNT'
<br /> ITTED C
<br /> J 1�
<br /> FEE [ /�
<br /> LESS
<br /> PRORATION
<br /> PLUS
<br /> PENALTY
<br /> OTHER
<br /> OTHER k
<br /> S/ 0
<br /> Received by leI Receipt No. Permit No. resuance Date Mailed Delivered
<br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P-O.Box 2069 STOCKTON,CA 95201
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