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Applications Will Be Processed When Submitted Properly Completed. <br /> : - APPLICATION <br /> f_.•= (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> k Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health DistriG1 }� <br /> Address <br /> k H Business Name (DBA) <br />{ a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> eBusiness Telephone No. _ <br /> Contractor Licence No. <br /> Title <br /> _ „,��t Date <br /> �. <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-1)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 /> f Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. <br /> ' ,. <br /> Equipment Parking Address"` - <br /> I 2. ❑ PUMPER YARD ' '�' <br /> t For July 1, June 30, 1: - ,: ; <br /> No. of Vehicles Stored + <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> t 4. ❑ SANITATION PERMIT 1 .� 37 <br /> Job Address/Location <br /> Owner �'a� C?SCs� Address 13 PACKAGE PLANT. <br /> TIC TANK ❑ CESSPOOL` ACHING FIELD ❑ .SEEPAGE PIT ❑ OTHER } <br /> # ❑ PERMANENT 0 TEMPORARY ❑ NEW �s ❑ REPAIR <br /> f 5- ❑ CHEMICAL TOILETS For July 1,-June 30, 19 - fi <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Site -Location(s) f <br /> g- 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 a Where Certified <br /> i Operator Name..: ' <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity t <br /> 7. ❑ LAUNDRY For July 1, -.June 30, 19 s <br /> SIZE: 11Less Than 1,000 Sq. Ft., 13More Than 1,000 Sq. Ft. Y _ <br /> +_ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. F <br /> r � -7San <br /> lCounty <br /> ,TI hereby certify thatA have prepared this,-applicaI.. . and.that the nic k will'be done in accorda <br /> ordinances, state laws, and rules and reg atio s of the Sari Joaquin Local Health District. . <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> x y: <br /> January 31- ❑ July 1 & By <br /> Fee Is DUe: ❑ ANNUALLY, <br /> ❑ PER UNIT © PER S1TF !r❑ EACH ❑ January 1 &Received By ReceiveRdEMITuly 31 <br /> r BILLING– -- ­'REMITTANCE $ AMOUNT DUE <br /> CHECKED <br /> ""' BASE :EXPLANATION ^OATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 3 <br /> PLUS <br /> .,PENALTY <br /> OTHER <br /> OTHER <br /> a G/ <br /> Date Receipt No. Permit No. <br /> I uance ate Mailed Delivered <br /> Received by- 1601 E.HAZELTON AVE.,RO-.-Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL.HEALTH PERMITISEAVICES - <br />