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Applications Will BeProcessedWhen Submitted Properly Completed. Be sure to atgn tne l+pPica. <br /> APPLICATION <br /> (K. Aon-Transferable, Revocable, and Suspendable,._, SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h eby/�ac! to carryon business in the jurisdictional area of the San400aquin Local Health District _ <br /> Business Name(DBA) (M�'(1(ZIS�.[ tt Sows_-Ti+iG Address f (.0. <br /> O 1'79>L� � <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Tel gphone Numbers <br /> 'n CY <br /> Business Telephone No �(g�-9� Emergency Telephone No. <br /> �Contractor Licence No. -- <br /> LApplicants Name (Print)�S _T F110 Title — Date 4 r/ <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. ❑ PUMPER YARD <br /> 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. )Q SANITATION PERMIT r� <br /> Job Address/ o tion <br /> Owner Address <br /> I�CSEPTIC TANK ❑ CESSPOOL LEACHING FIELD KSEEPAGEPIT ❑ PACKAGE PLANT <br /> .PERMANENT ❑ TEMPORARY XNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ 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 /> 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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ancjjules and regylations the S n oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> -9- a <br /> FOR DEPARTMENT USE ONLY \\- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE �O' AMOUNT DUE CHECKED <br /> (LAN DATE D T E TED S/ AMOUNT <br /> FEE <br /> LESS lX <br /> PRORATION <br /> PLUS a✓ O <br /> t � <br /> e, <br /> 6535 B� <br /> Date Receipt N, Permit No. Iss nm ate Mailed Delivered <br /> RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES lean E.HAZELTON AVE.,P.O.Boa 200 STOCKTON.CA 95201- <br />