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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> —rr (For Non-Transferable, Revocable,and Suspendable) <br /> `.� ENVIRONMENTAL HEALTH PERMIT 0l SEPTAGE <br /> LIQU10 WASTE �J <br /> s <br /> r Appl ica ion is hereby m de W carryon bus ne in the j ris fictional area of th an o }uin Local Health District q <br /> N Busines Name (DBA) ~Address CJ <br /> aOwner Address 3 <br /> Firm Partners, Addresses an Telephone Numbers <br /> aBusiness Telephone No. . Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) — Title Date <br /> Please check.Applicable-Category (1-7) and Fill in the Required Information 1 <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. CAL. License No: »a - CAL. Liccnse Renewal No. <br /> -Capacity - --_... Gal-Weights-&-Measures,No.' �- ^� 6 - -- - -- <br /> i <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _f R.S. or R.C.E. No. <br /> . _ <br /> Test Location ' t Test_Date/Time <br /> 4. O-SANITATION PER I " ti • r` <br /> 3 <br /> job Ad" <br /> _S Lan s/Location f <br /> Owner 1 Address 3 <br /> ❑ SEPTIC TAN ❑ CESSPO L-., IRILEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT AA <br /> [] PERMANENT ❑ TEMPORARY'S NEW PAIR ❑ OTHER <br /> 5. !❑ CHEMICAL TOILETS For July 1, ;,-June 30 19 ' `` <br /> Type Construction �� y _�-.Disposal Site <br /> No of Units Equipment Storage/Cleaning Location($) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1" June 30, 19 . <br /> Operator Name " Where Certified <br /> 15iant Location <br /> Plant Capacity No. Units Served ? <br /> -7.''D LAUNDRY For July 1, -June 30, 19 - -- _° i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 17— t <br /> ,.❑ DRY CLEANING, Chemicals Used/Amount/Mo. p - <br /> z t `-,zT _1 r"' <br /> -. - I hereby cert' _ t 1" ave prepareathis pplicationd that the work will.be done in accordance with San-Joaquin Countyordinance state`laws ' d rules antion kof th an Jo uin Local Health District. <br /> e ¢ <br /> APPLICANT'S SIGNATURE " <br /> FOR DEPARTMENT USE ONLY <br /> k <br /> Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT El PER SITE_ El EACH ❑ January 1 R Received By January 31 ❑ July 1 8 Received By Juiy 31 9 <br /> E t BILLING REMITTANCE $ REMIT <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE <br /> i LESS ' 1- # <br /> f' <br /> PRORATION # <br /> i PLUS <br /> i PENALTY <br /> OTHER • yf <br /> OTHER44 <br /> X <br /> w _ , <br /> i <br /> Received by - Date I Receipt No^- I Permit No + ....:� :'lssuance Date Mailed Delivered <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES '-.. .160TE.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i <br />