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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> 4 ENVIRONMENTAL HEALTH PERMIT <br /> f LIQUID WASTE <br /> Application is h eby?W d{to carryon business in the jurisdictional area of th San400aquin Local Health District _ <br /> rn Business`Na'me (DBA) Lir . i i�F RKIS Lt �� Z'�t' Address ;- ��sV ., . S'w <br /> zz Owner <br /> Address <br /> Firm Partners, Addre"sses a d Telephone--NI rs <br /> C a `TC�s Emergency Telephone No. <br /> ad Business Telephone No. — <br /> Contractor Licence No. <br /> .! Date <br /> M L Applicants Name (Print) 0 Title <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) � E{„ <br /> For July 1, June 3D, 19 Disposal Sites � <br /> Description(Make/Yr., Color) I <br /> Serial No. i CAL. license No. CAL. Licc Ise Renewal No. <br /> 1 <br /> e Capacity Gall Weights & Measures No. <br /> t Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored i <br /> No. of Chemical Toilets Stared. \ <br /> 3. © PERCOLATION TEST <br /> R.S. or R.G.E. No. <br /> R.S. or R.C.E. Name Y <br /> Test Locationl� Test Date/Time <br /> W.If <br /> 4. )Q SANITATION PERMIT <br /> o/ <br /> Job Address/ o tion <br /> Owner Address C <br /> ii SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT 11PACKAGE PLANT <br /> .PERMANENT ❑ TEMPORARY X NEW ❑ REPAIR [3 OTHER <br /> 15. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> f Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq: Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County o <br /> ordinances, state laws, an ules and reg ations the S n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY \,k <br /> 1 Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive January 31 E] July 1 &Received By July 31 <br /> REMl7 <br /> t BASE EXPLANATION BILLING REMITTANCE rr..�"' ,AMOUNT DUE CHECKED <br /> DATE DAT TSE TED AMOUNT <br /> FEE <br /> t LESS w _ <br /> PRORATION I[ <br /> PLUS <br /> PENALTY - <br /> t � <br /> OTHER <br /> i <br /> OTHER <br /> Received by Date Receipt No,- ..; _ _ Permit No - issuence kjaie Mailed Delivered' <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Banc 2009 STOCKTON„CA 95201 <br /> : <br /> .� =7, <br /> w r <br />