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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. } <br /> APPLICATION I' <br /> (For Non-Transferable, Revocable,,and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica ion Is hereby made to carry on busin sm the.jurisdictional area of the San Jolaquin Local Health District„ 1 <br /> OF Business Name {DBA} _ �[� � -�—1�� Fes _ Address <br /> a Owner l- V_iAL 1 Address - <br /> + ,a <br /> Firm Partners, Addresses a T lephone Numbe s ny <br /> IL Business Telephone.No. - Emergency Telephone No. x. <br /> .4 Contractor Licence No. , <br /> Applicants Name {Print}` tF7 SJA121 fa Title �` to - I <br /> 'Please check Applicable Category (1.-7.)and Fill in the Required Information r i•. <br /> QJ <br /> 1. ZTPUMPER VEHICLE PERMIT.REGISTRATION (FOR EACH VEHICLE) �J <br /> For July rr June 30, 19- ' ' -'-Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No: CAL.•License Renewal No. I <br /> Capacity Gal.,Weights &Measures 4--` ` = f ___J - <br /> Equipment Parking Address <br /> 2.'❑ PUMPER-YARD,-For July 1, June 30; 19 <br /> No. of Vehicles Stored - <br /> E <br /> No. of Chemical Toilets Stored <br /> x3.-0-PERCOLATION_ES'T__i_.....„, <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ` <br /> (Test Location Test Date/Time <br /> IF <br /> 4. ❑ SANITATION PERM T i <br /> Job Addr ss/L ation <br /> O ner n k Address <br /> SEPTIC TANK -❑ CESSPOOL'- -,=' LEACHING FIELD- SEEPAGE PIT ❑ PACKAGE PLANT, <br /> [❑ PERMANENT ❑ TEMPORANYa' f "NEW1`� t r REPAIR 13 'OTHER <br /> 15. ❑ CHEMICAL TOILETS For July 1, -r une 30, 19 t <br /> Type Construction Disposal Site <br /> INO. of Units i Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMILNT PLANT For July 1.'-June 30, 19 - - <br /> Operator Name- 1 Where Certified; Y 1' <br /> f Plant Location t ( # <br /> Plant Capacity No.Units Served i <br /> +7. ❑ LAUNDRY For'July 1,-June 30,'19; j <br /> i. � f <br /> fSIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> e - �_, .t ' <br /> ❑ DRY CLEANING, Chemicals Use�e ount/Mo.' ' <br /> Home•owrldirr'! ens d go is^i na±urnrer.ifiics-hoFo.ming:"Icertit"Ft,4*]n:'stftGrr^.'nceofiite%vorkforwhichthi r <br /> 1' yy s parrnif is issu ed,l shall not ompay i£n)person <br /> In Sl10tl manner 25'IG t}8CG7i1C SlESj.C[;:M'iC'111,,1��5,','3isi7C-ri5cl`!GTi�i�?'v'r�Of CE]I;iG;'t;iu.' - <br /> Cntitractor's: Wring or,sub-cortrncbng sig'ature ecr:fies, t:;e'followhig: "I certify that in0,0 perfarmanc2 GI lile war2c for whiclf ibis perp+t is issued,I shalt <br /> employ.persmissu jact.tb.ixprkrrrlmpa.nsation lases of , <br /> a'r I hereby certify that ve=preparedk thi. pplication and t t the work will be done in accordance with San Joaquin County <br /> 1�T k ordinance laws, n s and+regula ion f th Sari J aquin o al Health District. <br /> APPLICANT'S SIGNATURE <br /> " FOR DEPARTMENT USE ONLY . i <br /> i <br /> i ;❑ PER SITE 11 EAC ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: 1:1 ANNUALLY []'PER UNIT k <br /> REMIT <br /> ,g* BILLING HEMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> FEE 14 i <br /> LESS <br /> PRORATION a �- ;. '.t. I• ''� a - - J, <br /> f PLUS <br /> PENALTY <br /> I, OTHER <br /> N. <br /> ' OTHER <br /> Recbivnd'by Da Receipt No. - Permit No - Iss ante Date Mailed Delivered ; <br /> APPLICANT--RETURN ALL CO IES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA95201 <br />