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oe.p*oeeasod Whin Submitted Properly-Compteted. Be Sure To Sign The Application. �I ( <br /> APPLICATION l <br /> x <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE 1 ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> t -4 <br /> Applicati h Eby ay to c on us Hess in the' 3sdictional area of the�noa�quin calie �h Dtii�t� I I <br /> Business N.w (DBA) �� Address <br /> a Owner <br /> QAR61AE Address <br /> J Firm Partners, Addresses and Tel h n Numbqrs <br /> CL Business Telephone No. �' �' Emergency Telephone No. F ; <br /> a • 1 <br /> Contractor Licence No. <br /> 1� <br /> Title Date <br /> L Applicants Name (Print) <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) CAL. License Renewal No. k <br /> Serial No. CAL. License No. a i <br /> Capacity Gal., Weights t£Measures No. (, <br /> Equipment Parking Address _. <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 4 <br /> No. of Vehicles Stored A t4 <br /> No. of Chemical Toilets Stored 4 <br /> �a <br /> 3. ❑ PERCOLATION TEST - <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location , <br /> 4. ® SANITATION PER 13 Q i _I, I <br /> Job Addres_s,(L etion , � <br /> Owner _ f{ Address � <br /> 13❑ LEACHING FIELD SEEPAGE PIT 1:1 PACKAGE PLANT <br /> ❑ SEPTIC TANK 11 CESSPOOL <br /> OTHER <br /> y <br /> C3 PERMANENT ❑ TEMPORARY 11 NEW JO REPAIR 3 r ' <br /> 5. El CHEMICAL TOILETS For July i,-June 30, 19 Fr�krz 12�,� 'o �[,� r <br /> i Type Construction Disposal Site c� F <br />( No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name f, l� <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. 11LAUNDRY For July 1, -June 30, 19 ` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- ' <br /> f ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordancee w+th San Joaquin County T <br /> ordinances, state laws, and rules and regulations of the Sign Joaquin Local Health District. F. <br /> 1' APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> pp Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ .January 1 &Received By January 31 © July 1 &Received By Juiy 31 <br /> REMITJi I - <br /> tE, BILLING REMITTANCE $ AMOUNT DUE CHECKED I <br /> BASE EXPLANATION DATE DATE `^ REMITTED AMOUNT <br /> FEE ZT � 4 4 —S <br /> LESS Q Y ``. -, <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER <br /> w <br /> i <br /> r OTHER <br /> '_� <br /> - Permit No. 'N Issuance Date Ma'ded Delivered ,-# <br /> Received by - Rates �� Receipt No.. t <br /> Rat <br /> APPLICANT—RETURN ALL GOPIES,TO:. ENVIRONMENTAL HEAL PERMIT/SERVICES x€_ . `01 E.HA,ZELTON.AYE.,P.O_Box20e8—�STOCKTON,CA 9 01 1' <br />