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Applications ~r y Completed.Be Sure To Sign The Application�.� �,` � <br /> KATION `° •"" <br /> For Non-Transferable, Revocable;'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application'is hereby made togrry on business in the jurisdictional-area of the San Joaquin.Local Health District," •.. �� �: <br /> NBusiness Name (DBA)_ ^ � -Lec--- •r l' - Address :-, ;; !7 <br /> z Owner Address ; <br /> uFirm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No.. g Emergency Telephone No. _ <br /> -J Contractor Licence No, I <br /> Applicants Name (Print) Title ,� �y'�= Date <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) <br /> Serial No. a CAL7License No. <br /> - `' CAL. License Renewal No. j <br /> Capacity Gal.,Weights,&Measures No. <br /> Equipment Parking Address `� k <br /> i ) st <br /> 2. 11PUMPER YARD .. ....i - <br /> For July 1, June 30, 19 1 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST i _ > <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location <br /> LL{ocation ' a Test Date/Time <br /> 4. Jam,SANITATION PERMITI. 3 <br /> Job Address/Location -- <br /> Owner Address �� <br /> ❑ SEPTIC TANK ❑ CESSPOOL' ❑ LEACHING FIELD SEEPAGE PIT, ❑ -PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY .._ ❑ NEW � . REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July-1,-June 30, 19 <br /> 2. <br /> Type Construction Disposai,Sjte <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> &. ❑ PACKAGE TREATMENT PLANT For.,July,1, -June-30,19 <br /> LA <br /> Where Certified <br /> Operator Name <br /> Plant Location _ <br /> i <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY . For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ftj ❑VMore Than 1,000 Sq'Ft'-� <br /> ❑ DRY CLEANING, Chemicals Used/Amou"nt/Mo. <br /> or 4 !l. . <br /> I hereby certify that I have p pared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatso a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ~ <br /> �- FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By.January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ABASE EXPLANATION BILLING i REMITTANCE $ AMOUNT DUE CHECKED ` <br /> -GATE DATE REMITTED AMOUNT <br /> FEEY - Ale <br /> LESS <br /> "PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER � - <br /> OTHER M <br /> ! Received.by Date Receipt No. Permit No.,, I suancb bald. Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,�.c. _ Medi E.HAZELTON AVE.,P.4.Box 2009 STOCKTON,CA 95201 <br />