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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION � <br /> r ., (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> . .- ENVIRONMENTAL�IEALTH PERMIT <br /> } —7'7'� ac�J n//� ��; LIQUID WASTE l 'g- — �� US O <br /> Application is reb made to carry on business in the jurisdictional area of the Sa[�oaquin Local Health District <br /> m Business Name {DBA) ✓ b Address / t Q! 7 !�� <br /> z Owner <br /> Y' rr�.--/ crs� /Z__ Address ' <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) / /� Title 49 i' � l Date 7 <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 y <br /> Description(Make/Yr., Color) <br /> Serial'No. CAL, License No. CAL. Licz nse Renewal No. <br /> Capacity -Gal tiWekghts &Measures No. T r <br /> Equipment Parking,Address r <br /> _2.' © PUMPEI`YARD- <br /> For July 1,�y�, June30, 19 <br /> M. of Vehicles Stored <br /> No. of�Chemical.Toilets Stored <br /> 3. ❑ PERCOLATION TEST''" <br /> F'" "+#�. _- "' _ <br /> R.S.or R.C.E. Name `_.R:S:or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT C © � <br /> Job Address/Locatiori i le_ ®�""� /w Ge2 YS/ <br /> :� <br /> O�wn�e de M- rt'lCT�,ddress <br /> LW SEPTIC TANK ❑ CESSPOOL 9 C- `ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT f �j <br /> ❑ PERMANENT ❑ TEMPORAAY-0—NEW_— -- —11 REPAIR- []-OTHER----- <br /> 5. <br /> .OTHER-----5. ❑ .CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction t s Disposal Sitet, ''�_ �`A-- •- ` <br /> _ <br /> - No. of Units Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENT.PLANT For July 1, June 30, 19 <br /> Operator Name y Where Certified <br /> Plant Location 1 <br /> Plant Capacity {_ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> t <br /> I hereby.ce4rtify'that,I have prepared this application and that the work will be done in accordance with.San Joaquin County } <br /> ordinances,'sta'te'laws; and rules <br /> saaannd`regula ' ns of the San Jo�aquuiinLocal Health-District: - <br /> APPLI,CANT'S SIGNATURE X <br /> 4 FOR DEPARTMENT-USE ONLY <br /> l `; 11 <br /> ',Fee Is Due: 11ANNUALLY .� PER UNIT El PER SITE ❑ EACH- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31_ <br /> i- BILLING., t REMITTANCE �- � � $� � i- REMIT <br /> 1 BASE EXPLANATION .t }. AMOUNT DUE CHECKED <br /> i DATE E DATE REM T" s AMOUNT 1i <br /> SFEE 0�` -� S 1 <br /> 'LESS <br /> PRORATION <br /> !PLUS <br /> ;PENALTY � i 4 <br /> OTHER 4 <br /> Received by - Date - Receipt No. Permit No. Issuance Date Mailed Delivered n <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 ,ya <br />