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.. <br /> Applications Will Be Processed When SU <br /> APPLICATION. <br /> r <br /> ` (For Non-Transferable,Revocable, and Suspendable} SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictionaAada of the Q Joaquin Local Health District <br /> Hlip 11,111110 <br /> Business Name ( BA) Address <br /> i Owner <br /> X <br /> ,Firm Partners, Addresses and TeleQhone Number Emergency Telephone No. <br /> IL Business Telephone No. .� <br /> Contractor Licence No Title Date <br /> LApplicants Name (Print} T <br /> Please check ApplicableCategory (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color} CAL. License No. CAL. Li;y:-,se Renewal No. <br /> Serial No. �� ' <br /> Gal.,Weights &Measures No. <br /> Capacity . s <br /> Equipment Parking Address <br /> 2, ❑ PUMPERYARD �} <br /> f For July 1, June 30, 19 <br /> k <br /> No. of vehicle' Stored .� <br /> No. of Chemical Toilets Stored <br /> 3, ,❑ PERCOLATION TEST R.S. or R.C.E. No �. <br /> R.S.or R.C.E. Name '"Test DatV/Time <br /> f Test Location <br /> 4. ❑`SANITATION.PERMITy - '� `s C- r <br /> Job Address/Location, Address <br /> r{W 'A.+!;T <br /> ❑"PACKAGE-PLGEPYOwDer D SEEPA <br /> PTIC TANK- ❑ CESSPOOL �LFACFI [3 OTHERRC--NEW "PAI <br /> , <br /> LPERMANENT ❑ TEMPORARY <br /> --°� <br /> -"; <br /> June <br /> 5. ❑ CHEMICAL TOILETS For July 1 30, 19 <br /> CA ,`.- Disposal Site <br /> N <br /> Type Construction s <br /> ?Equipment Storage/Cleaning Locati8n(s) �� , <br /> No. of Units x� :# i <br /> I 8, ❑ PACKAGE TREATMENT PLANT, For July 1, -June 30, 19 --.. '"Where.Certified--� '� - <br /> Operator Name , E <br /> I, Plant LocationL No UT1its Served <br /> F <br /> Plant Capacity-' <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> Than 1,000 Sq' Ft. <br /> SIZE: 13 Less Than 1,000 Sq. Ft., w <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 <br /> ! • '.'. <br /> r application and that the work will be done In aocnT�dance with San Joaquin County , <br /> I hereby certify,that I-have prepared-this app <br /> ordinances, stateaaws, and rules and re I tioxnsf the San Joaquin Local Health District. <br /> - a i <br /> I APPLICANT'S`-SIGNATURE X ` t ` <br /> e `� - ✓'. t <br /> FOR DEPARTMENT USE O Y <br /> Received By January 31 ❑ July at &Received By July 31 <br /> PER SITE EACH Januar REMIT' <br /> Fee IS Due:-❑ ANNUALLY- ❑ PER UNIT a CHECKED <br /> 13ILLING CE $ AMOUNT DUE. <br /> 3 <br /> BASE EXPLANATION DAT E REMITTED - AMDUNT <br /> 4 <br /> v <br /> FEE i f, <br /> LESS <br /> PRORATION <br /> PLUS <br /> .i(. PENALTYf. - .....,- "�-- -.. ... .,... .... �. <br /> S OTHER <br /> OTHER r/� C13 <br /> Issuance Date Mailed Delliirveved <br /> `t' R ceiQt No.' Per it No. _ A TON AP.O. 2008 STOCKTON, : <br /> _ '--' Dale e - 1801 E.H ZEL � Y <br /> _ E.,P Bax CA�95201 <br /> ? - Received by - ,1 <br /> APPLICANT—RETURN ALL COPIES TO., 'ENVIRONNIENTA HEALTH PERMITlSERY10ES m y <br />