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:..2.._ v . <br /> `'Applications Will Be Processed When Submitted Property omp e e e <br /> APPLICATION <br /> �. <br /> (For Non-Transferable, Reaiacable,and Suspendable)" SEPTAGE�-� •.: <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> i Application is hereby made to cprry on business in the.jurisdictionalsrea of the San Joa in Local Health/District <br /> y Business Name (DBA) , <br /> /tf Address <br /> z Owner- Address l <br /> 4 W <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> Q <br /> { Contractor Licence No. Title Date <br /> f Applicants Name (Print) <br /> ' Please check Applicable Category (1-7)and Fill-in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> k For July 1, June 30, 19 -- Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity GaI.,.Wel hts_&_Measures_Nor <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> £ For July 1, June 30, 19 F 3_ <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> i 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location " .•- ' <br /> Address - - --- AP- <br /> Job <br /> " ❑ PACKAGE PLANT <br /> El SEPTIC TANK` ❑ CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT <br /> ❑ PERMANENT C1 TEMPORARY 13 NEW X REPAIR ❑ OTHER �� � <br /> 5. <br /> CHEMICAL TOILETS For July 1,-June 30,i9-�— i l� -- --R -- �-^�Rd <br /> Type Construction a Disposal Site <br /> i <br /> No. of Units f Equipment.Storage/Cleaning L c tion( <br /> f 5. ❑ PACKAGE TREATMENT PLANT.�-,Fzor July 1, -'�Jun_e 3.0, 19_ -- <br /> , Where Cerii led <br /> Operator Name <br /> Plant Location "T <br /> Plant Capacity <� `' No. Units Served 011- Y <br /> 7. 13 LAUNDRY For July 1, -June 30, 19 Ft- <br /> 0 <br /> -.� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More;Than 1,000 Sq. Ft <br /> - ❑ DRY CLEANING, Chemicals Used/Amount/Mo..' <br /> 1 <br /> x . . ~ <br /> 'c i ! <br /> I hereby certify that I�have prepared this application and that the-work wOl be done in accordance with San Joaquili County <br /> ordinances,:state laws, and rules and regulations of the Sara Joaquin�Local Health District. g <br /> Ad <br /> APPLICANT'S SIGNATURE X <br /> ` - <br /> FOR DEPARTMENT USE ONLY <br /> V , <br /> d By <br /> _ <br /> Fee i5 Due: 11ANNUALLYI ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By Januar_y 31 ; ❑ July 1_B,Receiv REMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE S s AMOUNT DUE CHECKED <br /> i DATE DATE 'REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION f <br /> PENALTY <br /> OTHER <br /> OTHER ._ <br /> Received by Date Receipt No, Permit No, <br /> Issuance Date Mai4ed r Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 t7' <br />