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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> I� APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> M LIQUID WASTE <br /> M Application' hereby mad too arry o uslne�m he ju Isdictional area of the n Joaquin Local Health Distr'ct <br /> i ��.L�. YtL. Address d C ,r7-S Z CI <br /> ,�Business N e (DBA) <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a a Emergency Telephone No. 3 <br /> CL Business Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) <br /> Title <br /> -� Date �! <br /> Please check Applicable Category(1-7)and Fill in the Required Information II <br /> 1. Cl PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. I CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. 4 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD f <br /> ` For July 1, June 30, 19 <br /> lVo�of Vehicles Stored A <br /> ( No.of Chemical Toilets Stored. <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. r <br /> y ` <br /> TestTest Date/Time 1 ) <br /> ,Lo �Ion p + <br /> 4. L9 SANITATION PERMIT /( <br /> ob Add /Locatio <br /> �-g Address r <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ PA'CKAG PLANT <br /> PERMANENTS ❑ TEMPORARY ❑�NEW �EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAWTOILETS For July 1p June 30, 19 <br /> Type Construction w A I,. Disposal Site R � <br /> No. of Units ft Equipment Storage/Cleaning Location(s) �) <br /> 4 <br /> r 6. 1:1 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 � <br /> Operator Name Where Certified <br /> r"i 1 <br /> I <br /> Plant Location. t <br /> Plant Capacity No. Units Served r p„ <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 1 ^ 1� <br /> SIZE: ❑• Less Than 1;000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> �. ❑ DRY CLEANING Gb miivcals,Wsed/Amount/Mo. <br /> I hereby certify that I have prepared this:ppllcatian and that the work will be done in accordance with Sa�ou�. <br /> ordinances, state laws, nd r les and regulatio`s of the San Joaqui Local H h Dist�ct. <br /> APPLICANT'S SIGNATURE X <br /> - FOR DEPARTMENT USE ONLY <br /> PER UNIT PER SITE '❑'EACH ❑ January i &Received By January 31 ❑ jily 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ <br /> i c REMIT <br /> i <br /> BASE ;' EXPLANATION BILLING ,REMITTANCE $ AMOUNTDUE CHECKED <br /> i DATE DATE REWTTED AMOUNT <br /> 1 <br /> I FEE <br /> LESS r <br /> PRORATION <br /> PLUS <br /> 1 PENALTY <br /> a- <br /> OTHER ri <br /> OTHER <br /> [_ Received 6y ' Date `. Receipt No. - Permit No. ssuan a Date Mailed Delivered <br /> -'APPLICANT RN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E:HAZE AV .Box 2009 STOCKTON,C A 95201 <br /> � �F <br />