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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application
<br /> APPLICATION
<br /> (For Non-Transferable;Revaoabie;and Suspendable) SEPTAGE
<br /> . 5 ENVIRONMENTAL HEALTH PERMIT
<br /> UQUIU WASTE"
<br /> Application is hereby made to car on business in the jurisdictional area of the San Joaquin Local Health Distri t (45,2.0rn Business Name (DBA) 1 Address I
<br /> aOwner V Address
<br /> J Firm Partners, Addresses and Telephone Numbers
<br /> IL Business Telephone No, �"9607 Emergency Telephone No.
<br /> 4.
<br /> Contractor Licence No.
<br /> L Applicants Name (Print) IS L ` Title bate
<br /> Please check Applicable Category(1-7)and Fill in the Required Information v Y€
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I~'
<br /> For July 1, June 30_19. Disposal Sites -- -'
<br /> Description(Make/Yr., Color) �J..,,....._.-.-.-. U, -t-
<br /> "".'."",..,`""«..."� CAL. License Renewal No.
<br /> Serial No. CAL. License No.
<br /> Capacity ( z Gal.,Weights & Measures No, _ ,(
<br /> t' Equipment Parking Address 1 - i�• d t �-
<br /> 2. ❑ PUMPER YARD'
<br /> Qr July 1, June 30, 19
<br /> No'IDf Vehigles'Stored t
<br /> No. of dhemida$Toilets Stored f ' 3•
<br /> r1 3. 11PERCOLATTONfTES4. i f
<br /> R.S. or R_SE Nanie t f R.S. or R.C.E. No.
<br /> r Tet L catioWi — ('tet Test Date/Time } •"
<br /> V 4. SANITATIC*0ERMIT-;r
<br /> Job Address/Location t zg
<br /> Owner 1i f, T -'" Address '
<br /> ❑ SEPTIC TANKS 0 CESSPOOL EACHING FIELD SEEPAGE PIT ;'�❑ PACKAGE PLANT
<br /> PERMANENT ❑ TEMPORARY ❑ MEW t REPAIR wf� OTHER {
<br /> S. ❑ CHEMICAL'TOILETS :For July 1, -June 30, 19
<br /> Type Constructione ; i Disposal Site i
<br /> No. of Units i `Equipment!WO ragelClean ing Location(s) t
<br /> 6. ❑ PACKAGE TREATMENT PLANT' For JJy 11'Jbne'30, 19 ")
<br /> 16�
<br /> Operator Name - --•- -- r - Where Certified;.
<br /> Plant Lo�cya)ionZ v Y•
<br /> Plant CapAc tye• `M"J ' No.Units Served
<br /> 7. 11"LAUNDRY For July 1,_-'June
<br /> 51Z '�.:..,❑Less Than 1 006 q Ft., ❑ More Than 1,000 Sq. Ft, � 14� �
<br /> l t 7
<br /> t
<br /> [T-DRY CLEANWbrl�csn eld'nas vsedSA 3iI'm 9yokfer4si?i;�thi t� iisis3uce ,,sl ,:l not employ any person
<br /> •. IRsuch maT1nFF'as t3
<br /> Corr! t6r'a Wr'nrt vy7 'ugh t,s7sgetY'Ig Irl , -.' r:�"-` :,.c rd S ;S�tfJ�i:ic.fl:;C'�tilC 4u'NI-,�� ,GI VihfGh t1iiS� ,;ni;is issued,i shall
<br /> - empio�r•'pBJsgn`Ssuliject to 4titarkltlati s coripen�ail��I��x�s C,l t,e,uctrt�la. $• �-} .•
<br /> 'I hereby certify that I have pared this application andlhad"the ?k will be dote in accordance With San Joaquin County
<br /> ordinances,-state laws, a ru d regulations the San Joa n Loca ealth District.
<br /> I -.�.
<br /> APPLICANT'S SIGNATURC � ��r
<br /> t � �• ) � �.� 'yam ��
<br /> . ; t ,..j,.- • _ - `ems°'`r�� � '':I
<br /> FOR DEPARTM NT U.SE_f)NI,Y - ,.• .. . -
<br /> Fee Is Due: 13ANNUALLY ElPER UNIT F 1:1 P911 SITE [IEACH ❑ January I &Received By,-January 31C" ❑ July 1 &Received By July 31
<br /> REMIT '
<br /> 1" B16L1Nd= REMITTANCE $ AMOUNT DUE CHECKED
<br /> i BASE EXPLANATION PATE DATE , REMITTED AMOUNT
<br /> FEE } al
<br /> LESS t• �` 9
<br /> PRORATIRN
<br /> ' PLUS
<br /> .,. ,......•OTHER� .,I,..�e.+.. e...�d,-,.., a-.�. ..� m..w.,�- �,..-- - �: '„' �.�. J.
<br /> OTHER .. ;...'�-5,
<br /> YeXY
<br /> A Gelved by.., Date Receipt No Permit Nn., Isffu, Ce ate Mailed ,r Delivered
<br /> STOCKTON,`CA 95201
<br /> ?APPLICANT—RETURN ALL COPIES TO: ENVIRONOEhU HEALTH PERMIT/SERVICES •1601-E.F.IAZELTON AVE P.O.Boz 2009
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