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Applications Will tae Processed When Submitted Properly;Completed. Be Sure To'5igri The� pplicatlon. ' <br /> v APPLICATION rk. <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> -- �- LIQUID WASTE <br /> Application is ereby made to carry_9n business in the jurisdictional area of the San��99agyicLLo)cal realth District <br /> H Business Name (DBA) Address <br /> aOwner Address_ <br /> 1 Firm Partners, Addre'sse's and Telephone Numbers <br /> aBusiness Telephone No. -- r Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ,al—G Title Date f � <br /> Please check Applicable Category (1-7)and FIII in the Required Inlormation h <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, - June 30, 19 Disposal Sites --- -- y <br /> Description(Make/Yr., Color) CP <br /> Serial No. CAL. License.No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br />+�. Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> t For July 1, June 30, 19 <br /> No. of Vehicles Stored – -� <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4: ❑ SANITATION PERMIT <br /> Job Address/Location- / 167 zd"197,4z� <br /> Owner <br /> r ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT. ❑ PACKAGE PLANT <br /> ElPERMANENT ❑ TEMPORARY Q,.NEW * ."� �REPAIR" <br /> ---:13 OTHER <br /> f€ 5. ❑ CHEMICAL TOILETS._For'July;1, -June 30, 19 <br /> s Type ConstructionDi"sposal'Site - <br /> No. of Units Equipment Storage/Cleaning Location(s) r` <br /> i 6. ❑ PACKAGE TREATMENT PLANT For July 1,,-June 30, 19 . <br /> i. Operator Name _ Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Servedr } <br /> 7. ❑ LAUNDRY For July 1,'-June 30, 19 <br /> SIZE: ❑ Less Than.1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 5 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with.San Joaquin Courity <br /> ordinances, state laws, and rules and reA610pna of the San Joaquin Local Health D_istnct 4. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> i Fee'Is Due: ❑ ANNUALLY_,. _❑ PER.UNIT _�❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By JYuly 31 <br /> -REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED, <br /> DATE �, DAT REMITTED I' AMOUNT , <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER T <br /> v .. - -n... .� .._ > �.:.-=..rte .'r.' � : • ..� �.r-�a,wwi..�. �_� rww ..-� _.-�. _ <br /> k Received by Date ,:Receipt No. Permit No. Issuance Date Mailed Delivered <br />€ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 •STOCKTON,CA 95201 <br />