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Applicalions4ill Be Processed When Submitted Properly Completed. Be Sure'To Sign The Application.
<br /> i� APPLICATION .
<br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Application is hereby made to,carry on business in the jurisdictional area of the S_arLjDaquin Local Health District
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<br /> Business Name (DBA) ICI L -w / e-4EK `Addr_ess
<br /> aOwner_ : .� . f�!,✓ ['"� Address V G
<br /> c-) Firm Partners, Addresses and Telephone Numbers 1
<br /> C1.
<br /> Business Telephone No. __ F � Emergency Telephone No.
<br /> Contractor Licence No. 01
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<br /> Applicants Name (Print) I Title Date I i
<br /> Please check Applicable Calegory (.1-7)and Fill in the Required Information f
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, - "June'30,1119, - = = Disposal Sites-
<br /> Description(Make/Yr.,Color)
<br /> Serial No. CAL. License No. CAL. License Renewal No.
<br /> Capacity II Gal., Weights & Measures No. ;
<br /> Equipment Parking Address_
<br /> 2. ❑ PUMPER YARD I '
<br /> For July 1, June 30, 19 `
<br /> No. of Vehicles Stored
<br /> ��... _�_.,,__-_.....-..._..4. - --- -----------•,-.-:..+•.�-«,..--.w-, .. _ _ ,....-......-..�.....-...-��.-y,=��_;_ ._ _._,,..A.�-..,.N--.-.,:..,.�--»-.,.�=F.-K.,_-wry,,.=..--.
<br /> No. of Chemical Toilets Stored' `
<br /> 3. ❑ PERCOLATION TEST �! �` �, .'
<br /> R:S:-or•R-C.E. No.
<br /> Test Loc tion �p Test Date/Time
<br /> 4. Lr SANITATION PERMIT �f / - „�r44` �.y �
<br /> Job Address/Localion `f � Y
<br /> Ow _'� ��+ . Address
<br /> SEPTIC TANK ❑'CESSPOOL ACHING FIELD 11 SEEPAGE PIT C3 PACKAGE PLANTk b t
<br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER
<br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 s f�
<br /> Type Construction >i. n.- W Disposal-Site
<br /> No. of Units C I Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July,1, -June 30, 19.
<br /> �,F` I �
<br /> Operator Name r Where.Certified
<br /> Plant Location
<br /> Plant Capacity. �� I i/ ! No. Units Served
<br /> 7. ❑ LAUNDRY For July 1, -June130, 19 =
<br /> SIZE: © Less Than,1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. x
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/,Mo. 46
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<br /> I hereby certify that I have prepar�d this application and that the-work will be doe l awo{ ante with �ta,in County
<br /> ordinances, state laws, ane rules a d gula ' sof th S�anr 113aquin Lgc86 Health District.� �
<br /> APPLICANT'S SIGNATURE X II -
<br /> q{. �P y_.- Y�y 1. W . .” ' �...�.............w-.-r....+,+�-..r,..wy.—..�..s•e...:.....-.._..-,-.a,..-...w..+:-•lir.
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<br /> ��p•t,FOR-DEPARTMENT USE ONLY >
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<br /> Fee IS Due: 17 ANNUALLY I❑ PER UNIT, ❑�PER S�TE r. ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By July 311
<br /> �^ A BILL`IN6 / ;_�AEMITTANCE $ E CHECKtD;-��
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<br /> BASE `';YEF�7(ALANkTk©N { Qj�;DATE ft; i t r- ' AMOUNTDUE
<br /> EMITTED AMOUNT
<br /> FEE ,,. ,!.
<br /> LESS I�
<br /> PRORATION
<br /> PENALTY
<br /> 3 }.1
<br /> OTHER ''I - s. Ilk
<br /> [fit
<br /> .OTHER.
<br /> Received by Date ;i - Receipt No, Permit No. - ssuan Date Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO:-, ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON'AVE.,P.O.Box 2009 STOCKTON,CA 95201
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