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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> A licati is hereb madeto car usiness in urls Ictional area of th�ySan Joa u oc alth Ism <br /> w Business Name (DBA) l y �s� ry �[LSTi1l Address Z.2o� /�r <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Tel numbers op <br /> aBusiness Telephone No. ty Emergency Telephone No <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date 7 y <br /> Please check Applicable Category(1-7)and Fill in the Required Information (S- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June,30, 1.9 Disposal Sites —4— <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights B'Mgasures No. <br /> r. <br /> Equipment Parking Address ~' <br /> 2. ❑ PUMPER YARD j <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST -i R <br /> R.S.or R.C.E. Name ' f- R.S.or R.C.E. NOT <br /> Test Locat" Test Date/Tir'n,e <br /> 4. ESANITATION PERMIT O / <br /> Job Add /Location - rt1?JI�� <br /> Owner o «1 Address—T4,4W 4S <br /> ❑ SEPTIC TANK ❑ CESSPOOL 9PtfZAING FIELD,, ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> ,,��V�-�•� w,ERMANENT ❑ TEMPORARY &'IQE170! 13 REPAIR ❑ OTHER <br /> 5. ❑ 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 July 1, -June 30, 19 a <br /> Operator Name Where Certifies! <br /> Plant Location <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I haveprepgr this application at the work will be done in accordance with Sjan Joaquin County <br /> ordinances, state lad s and r le nd regulatLoji an 4o in Local Health District, <br /> APPLICANT'S SIGNATU <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- `p PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Re6eived By July 31 <br /> REMIT <br /> BILLING REMITTANCE _ $ <br /> BASE', EXPLANATION AQUNTUE CHECKED <br /> DATE DATE REMITTED-' ,y� AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r '� <br /> OTHER C <br /> OTHER <br /> /-7 (y <br /> Received by Date Receipt No. Permit No. issuan a Dat Mailed. Delivered: <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21009 STOCKTON,CA 95201 <br />