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s Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />f APPLICATION _ <br />(For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />• Application is hereby made to carry on business in the jurisdictional area of the San Joaq in Local Health Distr'ct <br />3 p c3 <br />yBusineslame (DB , <br />Address <br />` �"' �} •�� �� Address <br />z Owne fir' <br />a <br />Firm Partners, Addresses and Telephone Numbers <br />aBusiness Telephone No. �`����. Emergency Telephone No. <br />Contractor Licence No.S3 <br />L Applicants Name-{Print4C�goiry <br />Title <br />Please check Applicabl(1-7) and n the Required Information <br />1. ❑ <br />PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, y June 3D; 19 `* T Disposal Sites <br />Description (Make/Yr., -Color). y _ �1 <br />`CAL. Liccnse Rencvaal No. <br />Serial No. CAL.•License No. <br />1 Capacity Gal., Weights & Measures No. <br />I Equipment Parking Address— <br />2. ❑ PUMPER YARD <br />k For July 1, June 30, 19 <br />No. of Vehicles Stored <br />No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST <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 j <br />Job Addre /L ation <br />� <br />own r w Address <br />1 SEPTIC TANK 1:1 CESS OOL LEACHING FIELD BEEPAGE PIT <br />Cg PERMANENT ❑ TEMPORARY�lM NEW ❑ REPAIR <br />5. 11 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 <br />tFor July 1, - June 30, 19 <br />',/', Date <br />) <br />❑ PACKAGE PLANT <br />❑ OTHER <br />Where Certified <br />Plant�Loca[ion�-- - <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. Ft. <br />0 -DRY CLEANING, Chemicals Used/Amount/Mo. <br />-. -� 1 <br />�ti" a itis <br />I hereby:certify that I have prepared this application and that.the work will be done in accordance daith San Joaquin County <br />:p;;ordinances, state laws, nd rules a re la'_tions of the San Joaq in Local Heakh District, <br />APPLICANT'S SIGNATURE X <br />f <br />i - <br />.w DEPARTMENT USE -ONLY. ---- --T- '.. <br />n n -000 nyp 1—I car -.H - ❑ .ianuair—v 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />. �� .� .....�. ,—• <br />— <br />- <br />_ <br />R ti..,�,s>,.. -_ <br />REMIT <br />BILLING <br />REMITTANCE' <br />$ <br />AMOUNT DUE <br />CHECKED <br />-- 6ASE <br />EXPLANATION <br />-- --_- <br />—�—DATE''—" <br />•^�— DATE....•.•.--_REMITTED.-- <br />'AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />_ <br />OTHER <br />_'k--130 <br />Received by Date Receipt Na Permit NO. <br />APPLICANT --RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERVICES <br />-r-M <br />1601 E. HAZELTON AVE., P-O..Bax 2009 STOCKTON, CA 95201 <br />