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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> s <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 busiiness in the jurisdictional area of the.San Joaquin Cal{ ea�lth Distric, <br /> Mr-Business Name (DBA) � , l ` Address_ <br /> I- <br /> Owner �-- �1 I-- TSL�— — Address <br /> Firm Partners, Addresses arLd elephone Numbers <br /> aBusiness Telephone No. S Emergency Telephone No. <br /> Contractor Licence No. 3j <br /> LApplicantsAame (Rrint) E r - Title Date _ <br /> Please-check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) { \ y <br /> For July 1, June 30, 19 Disposal Sites �+ <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL, Licc Ise Renewal No. <br /> ,yS g � <br /> Capacity'"' �'" Ga17Weights'' Measures.No- "'F <br /> E <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored. <br /> No'of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> Y R.S. or R.C.E. No. " <br /> R.S: or R.C.E. Name s <br /> Test Location ` Test Date/Time <br /> 4. Q SANITATION P MI <br /> Job Address/Location <br /> s Address <br /> Owner ❑ CKAGE PLANT <br /> ❑ SEPTIC TANK 11CESSPOOL LEACHING FIELD SEEPAGE PIT PA • g 1 <br /> 1:1 PERMANENT ❑TEMPORARY NEW REPAIR �. , OTHER <br /> Ya } 4 <br /> 5. ❑.CHEMICAL TOILETS.,For.July 1, -June 30, 19 f'± s 4 <br /> r ' Disposal Site t <br /> Type Construction i <br /> `• '�`• "`� � , . s <br /> No.yof UnitsEquipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For Jul 1, -June 30, 19 e <br /> Operator Name y Where Certified I• ' <br /> a . <br /> ,r-Plant Location t <br /> No. Units Served } ' <br /> -Plant Capacity i <br /> 7. ,11LAUNDRY For July 1, -June 30, 19 <br /> --SIZE: 11 Less Than 1,000 Sq. Ftr, ❑ More Than 1,000 Sq. Ft. <br /> a. <br /> ❑ pRY CLEANING, Chemicals Used/Amount/Mo. . <br /> L Y <br /> I hereby certif have prepared this application and.that the work will"be"done in accordance with-San Joaquin County "V <br /> g <br /> ordinances;st laws, rules and r lati ns oft San aquin Local Health District. *` ; <br /> APPLICANT'S SIGNATURE X Q2 <br /> L. t -- <br /> - 3 FOR DEPARTMENT USE ONLY <br /> r i <br /> " Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januaiy 1 &Received By January 3i- ❑ July 1 &Received 8y July.37,_ <br /> *LNGHEMl <br /> _.. REMITBASE EXPLANATION $ AMOUNTDUE CHECKED. REMITTED AMOUNTFEELESS <br /> PRORATIONPLUSPENALTYOTHEROTHER _ z <br /> r JJ <br /> If+ Received by Da Receipt No. ('Permit No. .,Issuance ex::' ailed Delivered <br /> i APPLICANT—RETURN ALL GOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21109 STOCKTON,GA 95201—� <br /> f <br />