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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Relrocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is her by made to arty on business in the jurisdictional area of the San q n Low Health District , <br /> y Business Name (DBA) r Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> CL 0. Business Telephone No. Emergency Telephone No.. <br /> Contractor Licence No. / <br /> L Applicants Name (Print) _ �—,J� �l[_iL� � Title Date <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, 119 = - 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 11 <br /> For July 1,_ _ June 30, 19 /•`" <br /> 3 J � <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST x <br /> -- `� R.S. orF.C.E..No. . +_ <br /> R.S. or R.C.E. Name 1 <br /> Test Location= Test Date/Time ti ' <br /> 4. '❑ SANITATION PERMIT o A x Cu <br /> Job Address/Location "'# G <br /> ,O,_,,,w, n��er •� <br /> ,o - /iI - Address i y <br /> W- EPTIC TANK ❑ CESSPOOL W—L"1 ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 L <br /> Type Construction _ Disposal Site �- -te t^ 1- � <br /> No. of Units - Equipment Storage/Cleaning Location(s) <br /> — _ 1 <br /> �6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ; 'Wille t <br /> _ °___ ' re Ce ified <br /> Operator Name 4. I <br /> Plant Location d <br /> _ No. Units Served ' <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June <br /> SIZE: ❑ Less Than 1,000 Sq�: Ft., ❑ More Than 1,000 Sq. Ft. { I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k+. <br /> t 4 ; <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, and rules and reguiat' s e Sanaquin Local Health District. i <br /> APPLICANT'S,SIGNATURE X <br /> FOR DEPARTMENT USE ONLY -> } € <br /> Fee Is Due-LD.�r�WALLY ❑ P_ER.-UNIT'. —D_PER.Sl7E_.._.❑_EACH...,..� ❑-January_]-&-Received_By-January 31 El July 1 &Received;By July 31 <br /> t - _ - , REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> { BASE A EXPLANATION DATE TE REMITTED <br /> r AMOUNT <br /> FEE s ! 5 -D i <br /> f <br /> LESS <br /> -PRORATIpIJ .7 , <br /> PLUS <br /> PENALTY ' <br /> THER <br /> .�- <br /> OTHER _ ,i;,# - •c 4. >..t'�, ' <br /> 10— T-} <br /> _ Received t)y Date Receipt No. Permit No. - - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />