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APPLICATION <br /> _ + (Far Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Apph do is her by ma to on nes i he jurisdictional area of the San quin L al Health Distr <br /> nBusiness e�DBA) Address 1 — <br /> Address - _0 <br /> aOwner - -- - � � <br /> 3 Firm Partners, Addresses and I elephon3umbers e <br /> / eele . <br /> CIL Business Telephone No. Emergency Telephone No. c <br /> Contractor Licence No. _ <br /> Title r"' - Date <br /> L Applicants Name (Print) — - <br /> Please check Applicable Category (1-7)and Fill In the Required information S <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.___ <br /> Serial No. CAL. License 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 � f' h <br /> 3. ❑ PERCOLATION.TEST k' R.S. or R.C.E. No. - <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. IV ANITATION PERMIT s t r <br /> Job Addres Locati n <br /> Owner � __ � Address <br /> ? lg LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ SEPTIC T NK ❑ CESSPOOL: REPAIR ❑ OTHER <br /> '❑ PERMANENT ' ❑ TEMPORARY ❑ NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> -+ Disposal Site - <br /> Type Construction - — y _ <br /> No. of Units Equipment Storage/Cleaning-Locations) -. <br /> ~r <br /> � <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - ��� G <br /> Where Certified <br /> Operator Name »' <br /> f Plant Location <br /> No. Units Served - <br /> Plant Capacity _ <br /> r <br /> 7. ❑ LAUNDRY For July 1, -June 30. 19 <br /> SIZE: El 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 appli io and that the work:wlll be,dono in accordance with San Joaquin County <br /> ( n Joaquin L6cal Health District. <br /> ordinances, state laws, and nd re ula <br /> � f _ <br /> APPLICANT'S SIGNATURE X - <br /> f <br /> n . <br /> 1 ° FOR DEPARTMENT USE ONLY , <br /> t Fee IS Due' [3 ANNUALLY C1 PER UNIT PER SITE EACH ❑ January 1 &Received By January 31 E] July By July 31 <br /> July 1 8 <br /> REMIT <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE RE ED AMOUNT <br /> LIS <br /> FEE � -� � / - <br /> LESS / <br /> C PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER - - -- <br /> Receipt No. Permil'No ISS ante to Mailed —Delivered o, <br /> Received by' Date . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />