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Applications Will Be Processed When Submitted Properly Completed'Be Sure To Sign The Application. s <br /> APPLICATION - ' <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is here y made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Ch Business Name (,DBA) dress <br /> z Owner �� Address ���/V <br /> Q f✓C <br /> Firm Partners, Addresses and e e hone umbers , 71 <br /> C6 <br /> � Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. rL Applicants Name (Print) t V 4 Title Date <br /> Please check.Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. El PUMPER YARD <br /> - s <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No.of Chemical Toilets Stored L } <br /> 3. ❑ PERCOLATION TEST <br /> i R.S. or R.C.E. Name .F R.S. or R.C.E. No. <br /> t Test Location Test Date/Time f , <br /> 4. ❑ SANITATION PERMIT f y <br /> Job Address/Locati n ���©O L <br /> C Address j <br /> mI SEPTIC TANK ❑ CESSPOOL Owner LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT * {{ <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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 _ <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> I " <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 have prep d t is appiica ion and that the work will le"done in accordance with �gaqui unty <br /> ordinances, state laws, and rule nd a ulation of the oa in Local Health District , �� <br /> APPLICANT'S SIGNATURE X - <br /> FOR'DEPARTMENT USE ONLY <br /> Fee Is Due:'❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> -.0 :� REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ , AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> t FEE <br /> LESS _ <br /> PRORATION <br /> PLUS - -'— <br /> PENALTY c <br /> OTHER <br /> OTHER <br /> � . 160V <br /> Received by Date Receipt No: Permit No. Issuance Date Mate Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES - 16011E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 - <br />