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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 /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE - 07(- oSt"4 L <br /> ` A ation is here made to carryn' sin s in the jurisdictional area of San Joaquin Local Health District. <br /> N Business Name (DBA) S Address <br /> aOwner Address F <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Qj{ [oQ-'Z _ Emergency Telephone No. <br /> a Business Telephone No. <br /> .JContractor Licence No. �� <br /> Applicants Name(Print) Title bate <br /> r <br /> Please check Applicable Category(1-7)and FII In the Required Information... <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J y <br /> For July 1, June 30, 19--. — = Disposal Sites - <br /> Description(Make/Yr., Color) J <br /> Serial No. CAL. License No" C's I','�-` "'� CAL'License F enewai Nq. <br /> ' 1 t ;.t N 1 1-- <br /> Capacity. Gal., Weights & Measur s No. <br /> Equipment Parking Address +^• f Q <br /> 2. ❑ PUMPER YARDI J ,; <br /> For July 1, June 30, 19 — <br /> No. <br /> 9 No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ,, <br /> 3: ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. f = <br /> R.S. or R.C.E. Name _._ .. <br /> Test Location Test Date/Time <br /> 4. 4 &,ANITATION PERMIT <br /> Job Add <br /> r ss/Locatio: -� C�2 s `SLI� <br /> Owner - ~- t <br /> ❑ SEPTIC TANK., _"� CESSPOOL �EACHING_FIE�LD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW XREPAIR 13 OTHER <br /> 5. ❑,CHEMIICAL TOILETS' For July 1,-June 30, 19 <br /> Type,'Construction { f rt Disposal Site <br /> NO. of�Units I�t� +•�- k ` - Equipment Storage/Cleaning Location(s) <br /> 6. ❑1PACKA`GE TREATIJENVALANT For July 1, -June 30, 19 <br /> Ope'ra'tor Name Where Certified ► - <br /> ' <br /> Plant LbcBtion' <br /> Plan)Capacity r �" - No. Units Served <br /> y7. 11LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Thari',1,000 Sq.-Ft., ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Horrwownee�ticsnsedan4'e I Is 1 thin[ttisl�tiihlaOritllatwhichthl9ttttta3tsissl�aA.istl8ltlotem YanYPersc;. <br /> glg�ylpttEfltYIfEampe�ti�rr IS� i•� <�R 11 -^ <br /> 11 <br /> In such rrrartaer as to bl as ; -; ttlai.ift tha peliaratartCid of t!�Rk for whilii tfiy6perrRitss;issr <br /> con"Votor's t�S w �� <br /> f- emptily perspn5 subject to wwtrtRall'S compe"Safte 1=5alcaliC!tela." ��Y <br /> I hereby certify that 1-:.,have epared this application and t t the work will be done in accordance with San Joaquin County <br /> �u ordinances, state laws, re'gul ns of th Joa in I Ith District. <br /> I" APPLICANT'S SIGNATURE X , <br /> tr <br /> , <br /> - .: 2, <br /> FOR DEPARTMENT:USE ONLY-- <br /> Fee Is Due. ❑'ANNUALLY ❑ PER UNIT a ❑"PER SITE--a EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> tREMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUSJT DUE t CHECKED <br /> t ri 4 „. DATE DATE ;" REMITTED i.n AMOU T , <br /> FEE•-L LESS <br /> ESS <br /> µ^' - <br /> PRORATION ' <br /> PLUS $ e <br /> PENALTY ti ' <br /> OTHER <br /> OTHER <br /> • Received by Date - Receipt No. j• 'Permit No. Issuance to 3 Delivered <br /> APPLICANT—RETURN ALL COPIES TO:�'ENVIRONMENTAL HEALTH PERMITISERVLCES ,a– 1601 E.'fiA2ELTON .O.Box 2009 STOCKTON,CA 95201 <br />