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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign ineRppncauon. <br /> APPLICATION <br /> (For Non-Transfera6le,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ma to busines "n"t a juri tional area of the. n J aqui oc I Health Di trict. Y, <br /> HBusiness Name (DBA) cldress <br /> eOwner _Address <br /> Firm Partners, Addresses and ne bers ' <br /> IL f Emergency Telephone No.- <br /> a Business Telephone No. - <br /> Contractor Licence No. <br /> Title, ate <br /> L,ApPlic nts Name(Pr.int) ' _ . <br />--' Please check Applicable Category,,(-1-7)-and Fill lin the Required Information <br /> t1.�-I]'PLIMPER-VEfitCFLEfPERMIT REGISTRATION (FOR EACH VEHICLE) - <br /> { _. s _ - <br /> -" y . w 3 Y i Disposal Sites _– --r <br /> For Jul i; June 30, 19 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL: License'IVo.f ^" � CAL License Renewal No. <br /> _ t <br /> -Capacity —'--G &M asur s-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 - { <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.'Name _ R.S. or R.C.E.No. <br /> Test Location,- Test Date µ <br /> 4. ❑ SANITATION PERtip{T� <br /> Job Addr ss/Locatio �L k <br /> Owner ) Address <br /> EPTIC TANK ❑ CES QL LEACHING FIELD SEEPAGE PIT * ❑ PACKAGE PLANT~ <br /> PERMANENT ❑ TEMPORARY U NEW REPAIR # ❑ OTHER 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30 19 <br /> Type Construction Disposal Site ' <br /> No. of Units EquipmentStorage/Cleaning Location(s) ' <br /> 6. AGE TREATMENT PLANT For July'1, -J30,797--7ne -� <br /> Where Certified -- ' <br /> Operator Name t <br /> Plant Location ; # <br /> Plant Capacity No. Qpits-Serve6 <br /> 7. El LAUNDRY For July 1, -June 30, 19 ,f'j d:c 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING ,Chdmicals Used/Amount/Mo. R F <br /> , <br /> �E;1`�1QIItEEI►}�`(�@I��i�,�iom���bii�ta+ir�:=:r;,, „�' �'�jtRatint,.e�r ortr'3�?;�.�y'• 9rr�ItC�r��eR'; �j ,: y . <br /> - �Iit.r�f�t;yt�fa�vs9rEaS�»orni;�, f .; ���rs eririii(REgS� sf�!lrsdf -i�ya�f��el`�ori <br /> hir.tl�!sr�ao!tt �iatt sirls'stttiie cG+ I#S L`!EC fttitln "I <br /> iz <br /> � s;ISuf�t'r.F;tb'�uu;krl�.�C-t�lpenaatian Eavr��-�,�ct.•.if ., g: Gtr:a�}� �n:tf7�9eJiflES�ah�`t�".T��„�fr�k-:t0i�rrrkEl!wy�t`IEs���rstit s Es51{ted;I�hrall <br /> 6A ! ,f re ared this plicatioh an t at t work will be donne in accordahce with San Joaquin County <br /> f5ereby_ce I v p P , <br /> 5 ordinances, to laws, an r nd regu!_ i ns h S In Joa u.l Lo Health�District. <br /> APPLICANT'S SIGNATUREX :� <br /> j; FOR DEPARTMENT,USE ONLY <br /> E .., <br /> Feels Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE El EACH14 ❑ January 1 &Received By January 3 July 1 &Received By July 31 <br /> _ REMIT <br /> t - BASE El(PLANATION BILLING //yREMITTANCE $ AMOUNT DUE CHECKED <br /> DATE ! 4 'DATE - - jREMITTED - a_�- AMOUNT <br /> FEE i 9' <br /> E. LESS ' y € - i"+1 <br /> PRORATION- - <br /> r { <br /> PLUS <br /> PENALTY <br /> OTHER.': -. - } ! -i: "' <br /> OTHER <br /> Receipt NO: Permit o. Issu Rce U ate ; Mailed Delivered <br /> Received, - - Date P -+ <br /> - APPLI NT— <br /> RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT%SERVICES` 1'601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95?01 <br />