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ApplicationsWill Be Processed When Submitted PA.0perl7"� p
<br /> ...am feted. Be8e S sure To Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable;and Suspendable) ~�
<br /> ENVIRONMENTAL HEALTH-PERMIT SEPTAGE
<br /> LIQUID WASTE_., •`
<br /> r Application ' hereby rrlad o carry business in the jurisdictional area of t San oaquin.Local Health District _ s
<br /> c, Business Name (DBA)
<br /> aOwner _- €Address I
<br /> Address +r' -_ f
<br /> 1 Firm Partners, Addresses and Telepho+e Numbers '
<br /> CL Business Telephone No.
<br /> ncy Telephone No.me
<br /> � rgeContractor Licence No. E
<br /> ' �� � 4 y�
<br /> L Applicants Name(Print) � �� � � rtM w -
<br /> Please check Applicable Category(1-7) and Fltl in the Required Information, Title Date, I
<br /> -r 4
<br /> i. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1,. June 30, 19 - -
<br /> :Disposal Sites•.
<br /> Description(Make/Yr., Color) f -
<br /> Serial No: CAL. License No.
<br /> Capacity_ CAL. License Renewal No.
<br /> Gal., Weights & Measures No.
<br /> Equipment Parking Address �
<br /> 2. ❑ PUMPER YARD -
<br /> For July 1,_ : June 30, 19 { .�
<br /> No. of Vehicles Stored A. t
<br /> .No. of Chemical Toilets Stored t
<br /> 3. ❑ PERCOLATION TEST ' i
<br /> R.S. or R.C.E. Name
<br /> Test ovation �� ' -
<br /> R.S. or R.C.E. No.
<br /> 4. SANITATION PER IT - - Jest Date/Time
<br /> Jab Addr S/L.ocation
<br /> Owner
<br /> Address
<br /> X iSEP C TANK, ❑ CESSPOOL ti LEACHING FIELD ❑ SEEPAGE IT PACKAGE PLANT
<br /> PERMANENT ❑ TEMPORARY, NEW ❑ REPAIR ❑ .OT.HER T
<br /> 5. ❑ CHEMICAL TOILETS For July t1, -June 30, 19 '7
<br /> T s
<br /> ype Construction t - __ Disposal Site t r
<br /> No. of Units r Equipment Storage/Cleaning Location(s)
<br /> 8' ❑ PACKAGE TREATMENT PLANT 'For July 1,-June 30, 19 t t
<br /> Operator Name
<br /> Where Certified
<br /> Plant Location { 1 c .I
<br /> Plant Capacity
<br /> No.Units Sewed� - '
<br /> 7. El LAUNDRY For July 1, -June 30,.-19
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,! '70" ore Tharc1000 --
<br /> , .Sq..FtA' I
<br /> q , c a
<br /> ❑ 11A]' 4EANING,Chemicals Used/Amolnt/Mo. t — -
<br /> Homeownerorlfeene # {,
<br /> adn "Kass, nAturrr �r�;fteSt'tsfo.lo.rin tlertif Iha�iinthe -r?rforrnanceaf[heuorrferlyhici}thispermifisIs f" A
<br /> in such man�rFr t1s to become slrl i ��o e��ofl pran',campens�i�on i$�;s cf*' y
<br /> Contractor s P I t
<br /> hI`snfl or sorb-ccnt t=.E ;s, n �jjfirinia" susd,Ishalin04emPfo yan
<br /> employ personsslitJ } 4 ai re rerilfl. fls uilovr "j F YR ""^
<br /> Ct 'lOr,..,i� i EDI' } c n17= certii,i.}1i iIF the perk":Ti^.L"^: fin S i.".'C f3Y'1hi.^l±!;,Is pC'ri itt i3 F SllClf.}8hc:1
<br /> ':J?j�� I&44G UE{,` {IiQlTliu._-,+ •--I.. __ _� -
<br /> I hereby certify that 'I'have- ir8pared this application and that the work will be done iri accordance with San Joaquin County 4
<br /> ordinances, state laws, and rules and.reg lation theSan Joaquin Local Health District. c�
<br /> APPLICANT'S SIGNATURE'X
<br /> " FOR DEPARTMENT,USE ONLY
<br /> y e ti4
<br /> Fee IS DUE: El ANNUALLY ❑ PSR UNIT' ❑,PER SITE . ❑ EACH' ,❑ January 1.8 Received By.January 31 ❑ July 1 &Received By July 31
<br /> 'BASE EXPLANATION BILLING REMITTANCE $ n %: REMIT
<br /> DATE. PATE —REMITTED-
<br /> DATE. �'- ,�AMOUNT.DUE CHECKED
<br /> FEE.:. �� - AMOUNT
<br /> LESS
<br /> PRORATION y -(
<br /> PLUS r l:. _
<br /> k ~ -
<br /> PENALTY _ , •• 1•'i-,"3 .:.� .r ,n '• 7
<br /> OTHER _
<br /> .OTHER W
<br /> Received by Date
<br /> Receipt No. ermit No. nuance pate Mailed
<br /> f APPLICANT-RETURN ALL COPIES TO:! ENVIRONMENTAL HEALTH PERMIT/SERVICES-'^•"-' Delivered
<br /> '"16ot E.HAZHLTON AVE.,P.O.Box 2008 TOGKTON,CA 95201
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