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AppiicationssWIll Be Processed When Submitted Properly Completed. BeSure Io algn ineAI1�lIlVa.,v... <br /> . _ . <br /> APPLICATION `. <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> w} ENVIRONMENTAL HEALTH PERMIT <br /> ' LIQUID WASTE <br /> I <br /> App lIcati Ji iereby made to carryon business in the jurisdictional area of theme Joaquin Local Health District <br /> Address +2t]+ <br /> .Business Name (DBA) <br /> ! Address <br /> aOwner - ) <br /> Firm Partners, Addresses and Teleph ne Numbers Emergency Telephone No. <br /> E6 Business Telephone No. <br /> Contractor Licence No. ry y � Date <br /> Applicants Name (Print) ' Title <br /> Please check Applicable Category (1-7)and Fill in the Required Information Cl..fi:?EPgCE'$ SEPI IC ' S V'�CR SER�,16E r� <br /> 1. ❑ 23 So. Oro * Stcci,ioil, Calif. 95205PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE} i; <br /> For July 1, June 30, 19 ill Disposal Sites <br /> Description (Make/Yr., Color) IM CAL. License Renewal No. <br /> Serial No. �M CAL. License No. <br /> CapacityIN, Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 I� <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> r R.S.or R.C.E. Name <br /> IM Test Date/Time <br /> Test Location <br /> 4. X SANITATION PERMIT <br /> Job Address/ catio tl <br /> JPcaner Address 13PACKAGE PLANT <br /> SEPTIC TANK 11CESSPOOt LE CHING FIELD ❑ SEEPAGE PIT <br /> LYOTHPERMANENT ❑ 11TEMPORARY VNEW REPAIR ev <br /> ER <br /> 5. 11 CHEMICAL TOILETS For`I�.July 1, -June 30, 19 Disposal Site y <br /> Type Construction <br /> No. of Units . Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> :. Where Certified <br /> Operator Name �M I <br /> Plant Location �M <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> �� 11 More Than 1,000 Sq. Ft. <br /> SIZE: El Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> i <br /> (. 1 hereby certify that I` have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, r I nd regulations of th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X wC `PTIC 8 S'EWLR SERVICE <br /> �t):�i'S'J.fro � •SCCG�iipi� <br /> 7AM:)UNT <br /> it FOR DEPARTMENT USE ONLY <br /> F Fee Is Due: ❑ ANNUALLY Ji ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 & REMITd By <br /> { 1� BILLING REMITTANCE $ AMOUNT DUEd By <br /> `I BASE EXPLANATION DATE DATE REMITTED <br /> ® dE <br /> ® G <br /> FEELESS <br /> `�T IIII <br /> PRORATkON <br /> , <br /> 4 PLUS t� <br /> PENALTY ! 4� <br /> OTHER <br /> I OTHER <br /> '. <br /> Permi[ o.D . Issuance Date M i Delivered <br /> ' a Receipt No. <br /> Received by .w 1601 E.HAZELTON AVE,,P.O.Boa 2009 � STOGKTON,CA�952x1 <br /> APPLICANT—RETURN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> Il - ... <br />