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APPIWellApplications1 Be Processed When Submitted Properly Completed.-Be Sure o Ign e <br /> APPLICATION <br /> (For Non-Transferable, Revocable"and Suspendable)' SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> 1 Application i V928ade toll,90yonbu the i ss in jurisdictional area of the Sai Joaquin Local Health. stric a <br /> 1� R:Address <br /> F Business Name (D A) .. <br /> �, it �..�� Address ,, n <br /> a Owner -- Y a . <br /> R Firm.Partner's, Addresses and Telephone Numbers <br /> f Emergency Tel <br /> No. . <br /> IL Business Telephone No.: i. r' <br /> a Contractor Licence No.w _ ` <br /> 1 Title „ Date <br /> Applicants Name (Print) y. <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) CAL License Renewal No.. r <br /> Serial No. CAL. License NO. <br /> Capacity Gal.,Weights & Measures No. <br /> r <br /> Equipment Parking Address y <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored, <br /> No. of Chemical Toilets Stored . ` <br /> 3. 0 PERCOLATION TEST - <br /> .. R.S. or R.C.E.No. <br /> c R.S. or R.C.E. Name <br /> Test Location. Test Date/Time ' <br /> I 4. ❑ SANITATION PERMIT <br /> 'Job Address/Loc d" <br /> tlA Address C <br /> Owner ❑ PACKAGE;'PLANT <br /> is <br /> 13 SEPTIC TANK ❑ CESSPOOL p .EA'l FIELD SEEPAGE PIT X <br /> 11 PERMANENT 11 TEMPORARY ❑ NEINREPA R ❑ OTHER v a <br /> 5. # <br /> E] 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 i, -June 30, 19 Where Certified <br /> Operator Name C <br /> Plant•Location ' <br /> ? e;.; t h ?. No. Units Served <br /> Plant-Capacity•-} <br /> 7. ❑",LAUNDRY Fol-June-30, 19 <br /> SIZE: 4"'❑ Less Than 1,00Q,SAq: Ft., ❑ More Than 1,000 Sq. Ft. <br /> .❑ DRY CLEANING, Chemicals Used/Amount/Mo. -- - <br /> 'eHortleowneenrticensedagent�sslgnaturer ti le,t eolloonfg:1C rllfyF�air.�;hEPp`�?ermanceolthework for�.�hichthis permit is'sssued,Ishall not empluyassYperson� <br /> in such Inartt er as to become s;sbjcct to irc,k a ' !� <br /> . � Casztracior's hiring orfsub-cor�lractirg ;�;�nu*-�'� `.:r°'�� :`~ fal�p�:srag: 1 certify"�;t ir;ttte perturmalt�ee n4 the t=rEirk for which this permit is issued,l sha <br /> -,employ persons subject to.rycicman's c i pcllsat: n <br /> i 3 hereby certify that I have pre red thi application and that the.work will be done in accordance with San Joaquin County <br /> ordinances,'state laws, and r nd r ulatio of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Xy t <br /> t, ( FOR DEPARTMENT USE ONLY <br /> ' 'ANNUALLY ❑ PER UNIT El SITE El EACH ❑ January 1 &Received By January 31; ❑ July t &Received By R REMIT 31 <br /> Fee Is Due: ❑ <br /> REMITTANCE $ r <br /> BASE EXPLANATION BILLING AMOUNT DUE CHECKED <br /> ., DATE - DATE REMITTED AMOUNT <br /> FEE <br /> } <br /> PRORATION; Qi <br /> d PLUS - q _ f.. <br /> -PENALTY 's <br /> 1' 1 <br /> _ OTHER ' <br /> OTHER, <br /> r <br /> p` 3 <br /> :. -.. r rR : ,v, <br /> Issuance Date Mailed. Delivered <br /> I. Received by ,.,r Date t ` Receipt No. Permit No. <br /> " 1661 F.HAZELTON AVE.,P.O.Box 2009 STOCKTDN,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'NEALTH PERMI7ISERVICES I <br />