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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> `" ' 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$ar�. Joaquin Local Health District11 ' <br /> ,Business Name (RBA) Address �• <br /> a Owner— I. • ;ter!f f' Address <br /> ,Firm Partners, Addresses and Telephone Numbers - w <br /> a Business Telephone No. Emergency Telephone No. <br /> d f 2 <br /> Contractor Licence No. s2!�i <5_0C Date <br /> Applicants Name (Print) - Title <br /> Please check Applicable Category (1-7)and Fill in the Required Information k <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL, License Renewal No. <br /> Serial No. - CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address = . <br /> 2. ❑ PUMPER YARD <br /> s <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored l -� <br /> No. of Chemical Toilets Stored �1 <br /> 1 <br /> 3. ❑ PERCOLATION TEST <br /> • R.S. or R.C.E. No. � <br /> Test Location <br /> R.S.or R.C.E. Name <br /> i Test Date/lime <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ('? <br /> Ow , Address s <br /> _, <br /> El LEACHING`FIELDF ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> I SEPTiC TANK . .R �.a ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW i.© REPAIR <br /> 5. ❑ CHEMICAL TOILETS For-July i, -June 30, 19 a <br /> Type Construction = ,Disposal Site <br /> Equipmen'CSforage/Cleaning Locations) I <br /> No. of Units - i �y � <br /> 6. ❑ <br /> -PACKAGE TREATMENT PLANT For July 1,-=June 30, 19s Where Certified <br /> j Operator Name <br /> r <br /> Plant Location 'N- <br /> ` <br /> 3. a No. Units Served <br /> Plant Capacity f^ o 4 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ; <br /> f SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> w .� { <br /> '- <br /> I hereby certify that i have-prepared this application-arid that the work will.be done in accordance with San Joaquin County <br /> ordinances, state laws,.and rules and r ula"ons off theSan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r FOR DEPARTMENT USE.ONLY <br /> a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT :: ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 July 7 Received By July 31 <br /> _ _ REMIT X <br /> -611 �°�BiLLING"'��"�-REMITTANCE - $ :AMOUNTDVE CHECKED ' <br /> G <br /> BASF EXPLANATION DATE DATE EMITTED - AMOUNT <br /> i <br /> FEE 3e „ <br /> ice^ <br /> Fy LESS <br /> I- PRORATION - <br /> i <br /> PLUS <br /> PENALTY <br /> ' p OTHER_ <br /> OTHER <br /> "- Issua c Date Mailed Delivered-,.,- <br /> Received by Date Receipt No. 779 ermit No. <br /> h - APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMITlSERVICES, 1601,E.HAZELTON AVE.'P.O.Box 2009 STOGKTON,CA 96201 <br />