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Applications Will Be Processed When S ibmitted Properly Completed.Be Sure To Sign The Application. ? <br /> APPLICATION <br /> ^ (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica • n is�h reby ade t carry on bu in sin t jurisdictional area of th Joaqu" Local Health District , <br /> yBusine ame (DBA Address <br /> aOwne Address. <br /> Firm Partners.Addresses and Tel pho a Numbers <br /> CL a Business Telephone No. Emergency Telephone No, <br /> Contractor Licence No. <br /> a Applicants Name (Print) Title Date <br /> 4Piease chedc.;Applicabie. gory(1-7)and FIII in the Required Information } <br /> 1. ❑ PUMPER--VEHICLEP'ERMIT REGISTRATION(FOR EACH VEHICLE) # <br /> For July-l� L °'`June 30, 19 Disposal Sites <br /> Oescnption(Make/Yr_;Coi', } - <br /> Serial No`- �` '' CAL. License No. CAL. LicCnse Renewal No. <br /> Cap'a�ity Gal.,Weights &Measure No. <br /> Equipment Parrking•Address_ <br /> 2. Oi PUMPER YARD,' + <br /> For July 1.__ June 30, 19 <br /> No.of Vehicles Stored `.No.of Chemical Toilets Stored <br /> 3. E] PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S..'Or R.C.E.No. � <br /> Test Lo tion Test DatdlTimes° <br /> 4. II SANITATION PE T y r' '` 114 <br /> r <br /> Job Addr s ocation <br /> Owner :: :Address :.. ... aV <br /> 1:1SEPTIC TAN ❑ CESSPOOL ©~LEACHING-FIELD ❑�SIEEPAGE PIT ❑ PACKAGE PLANT14 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW "'R;-REPAIR <br /> c. ❑ CHEMICAL TOILETS F.or July 1,-June 30, 19 <br /> pe Construction Disposaltite6A <br /> ,.o. of Units Equipment Storage/Gleaning Location(s) }}' <br /> i. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30tii`19 <br /> Operator Name Where Certified ± t( <br /> Plant Location -" ! <br /> Plant Capacity �_ •.:r No:. nits Served— f <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 �q. Ftp r , <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. .� i ; <br /> c. e ownero•f r.^.r<s3d 1121 na`s xiartsture cEri^..ca+h�;atic�vny:"I ce1*ity that tti f;,s per'�r ,a t`ce G'thC r�ork tGr vrhiCh th i3 permit is issued,t shall rant employ any{arson <br /> I?SL+rh;ti7le�1 S iU 7ef;,rfi? ' <br /> iron*rdC[Or'S i;Ci;t i��,ri Pl;d' �0'iN2:ucirl�ll EONS vs Com'!! :iti!.' . <br /> nivir',y )sta4 ::� ::f: 7 <br /> Em IC ori ^r :i-Gurli:9t::0! ;:r term ce.::iia ib� ?o. ':ei '?,Cr:f•V';!%i L..!.1�pC:;r;.'aa;+CS C•1 Ii1C e-=r.lOr INhiCh tlai5 y°^Tl' iSFLIG'd,I Shall <br /> p l'P OI S 31t ;2 t t ~;105111:.ri Jd:1C!:58ii0II i:itiL�.(',;;iiG'?.:d, <br /> I hereby certify that I have prepared this application and.,that the work will be done in accordance with San Joaquin CounKy <br /> ordinances, state laws,and ules and regu ion of the San Joaquin Local Health District. } <br /> t <br /> APPLICANT'S SIGNATURE X <br /> } <br /> FOR DEPARTMENT USE ONLY <br /> a <br /> Fee Is Due:❑ ANNUALLY ❑PER UNIT ❑ PER SITE? ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Received ay July 31 <br /> REMIT e <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE -CHECKED <br /> JDATE DATE REMITTED' 4AMOUNT <br /> FEE <br /> LESS <br /> PRORATION � <br /> PLUS ° <br /> PENALTY ANI <br /> w I <br /> OTHER y! J <br /> OTHER + ! f <br /> Received by Date Receipt No: '� Permit No I"iJartod Date Mailed Delivered <br /> 1801 E.HAZELTON AVE.,P.O.Box 2009 BTOCKTON,CA 96201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />