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Applications Will Be Processed When Submitted Properly Completed. <br /> APPLICATION <br /> ,. (For Non-Transferable,Revocable, and Suspendable) SEPTAGE. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> :x LIQUID WASTE <br /> Application is hereby made to carr on business in the jurisdictional area of the San oaquin Local Health Distrio <br /> ,�, <br /> Business Name (DBA) Address <br /> Owner Address <br /> i pd <br /> a <br /> Firm Partners, Addresses and Telephone N Emergency Telephone No. <br /> G. <br /> Business Telephone No. <br /> Contractor Licence No. Date <br /> Title <br /> Applicants Name (Print) V m <br /> Please check Applicable Category(1-7)and Fill in the quired Information <br /> i i. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> f Serial No. CAL. License No. <br /> Capacity is Gal.,Weights &Measures No. <br /> f Equipment Parking.Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, 'June 30, 19 <br /> No. of Vehicles Stored s <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 <br /> 4' "' Test Date/Time <br /> Test Location `: <br /> 4. ❑ SANITATION PERMIT <br /> Jab Addr�slLocation._ <br /> MM �� j�103CEJSSPOOL <br /> '"Li` Z RIC Address <br /> Owner ❑ PACKAGEPLAIVT <br /> EPTIC TANK Pm e�ACHING FIELD ❑;SEEPAGE PIT <br /> r ❑ PERMANENT ❑ TEMPORARY ❑`NEW ❑-REPAIR ❑POTHER <br /> 5. ❑ CHEMICAL TOILETS For'July 1, -June 30, 19 X <br /> Type Construction 4 ': Disposal Site <br /> No. of Units } Equipment Storage/Cleaning Locations} <br /> V • s.. <br /> 6. ❑ PACKAGE TREATMENT PLANT For'July 1, -June 30, 19 Where Certified ` <br /> Operator Naine — <br /> Plant Location <br /> Plant CapacitNo. Units Served <br /> y: �' -- r �- -; Tp <br /> 7. 11 LAUNDRY -.For July 1, 'June 30,"g9 <br /> +E "r <br /> SIZE: 13 Less Than 1,000 Sq. Ft:,""") 0 More Than"1,000 Sq. Ft. <br /> ❑ DRY CLEANING,-Chemicals Used/Amount/Mo. J�,(yJR.{�/ <br /> f- `and that the work will be done in accordance Jo�in C .unty <br /> Ifiereby certify that 1 ha e.prepared this a plication <br /> ordinances, state laws, and rules and re tion f the San 0 quin Loc I Health District. y F <br /> (. APPLICANT'S.SIGNATURE X "- - <br /> ` <br /> FOR DEPARTMENTUSE;ONLY _. <br /> is <br /> Fee Is Due: ❑ ANNUALLY ER UNITt „e, 0 PER SITE &Receivod By January 31 July 1 &Rerelved By EACH January - ❑ REMITuiy 31 <br /> iyBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> # BASE + EXPLANATION DATE DATE REMITTED AMOUNT, <br /> �- FEE 45 C—”" <br /> PRORATION <br /> � t <br /> PLUS , <br /> PENALTY . .;�;y. �,�r,�, '• '* -. <br /> OTHER - <br /> Ir <br /> W Delivered <br /> Mail <br /> eceived by Date <br /> Receipt No. - Permit No. - Iss ance a e - <br /> 1661 E.HAZELTON AVE.,P.O.Box 2069 STOCKTON,CA 95204 <br /> APPLICANT <br /> —RETURN COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> - <br />