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Applications.Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> { <br /> LIQUID WASTE = • � � <br /> Applica ' is hereby o <br /> made carry, busi ess in e' ris 'ctional area of th�nJoa in Local Health Distric r <br /> NBusine s ame (DBA) f Address-. <br /> +_ Owne Address - <br /> a <br /> Firm Partners, Addresses and Telephone umbers <br /> IL li,Q.r k 8, Emergency Telephone No. <br /> a Business Telephone No. y - <br /> Contractor Licence No. _Z <br /> L Applicants,Name (Print} <br /> Title Date <br /> t 1 <br /> Please-check Applicable C ory(1-7] and Fill i e Required Information , - <br /> _ 1 ❑:PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> fjj_:- ' s 1 4 - _:"Disposal Sites 1 <br /> For July,1' June 30;,19 <br /> e' Description(Make/Yr.,Cold ) <br /> "4 - • . CALLicense No. CAL. Renewal No. 1 <br /> Serial No. . --J <br /> '�,E':_ Gal.,Weights &Measures No. <br /> Capacity-_ g <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, `''June 30, 19 t <br /> Na. of Vehicles StoFed <br /> No. of Chemical Toilets Stored <br /> —3 ' ❑_PERCOLATION TEST <br /> RIS:or R.C.E. Narrie - R.S.or R.C.E. No. <br /> dest,,Lo �ton Test Date/Time <br /> 4.f'ilea .6AN_1TASI6N PERMIT <br /> Job Addr /Lo tionow r t <br /> ` Address ; <br /> ., ❑ SPOOL" 't, EACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANT + <br /> i L�7.,/SEPTIC TANK <br /> PERfiIIANEN ❑ TEMPORARY NEW REPAIR �- <br /> I(� i �._ <br /> 5:r:❑ CHEMICAL TOILETS For July Jun 30, 19—, 1 �� <br /> Disposal Site <br /> - Tjipe Ca structiorf l <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Named <br /> .Plarif Location, <br /> A -Capacity No. Units Served <br /> Plant <br /> 7. ❑ LAUNDRY`°For July 1, -June 30, 19 <br /> r <br /> SIZE: ❑ Les T,han..1,000 Sq. Ft., ® Mare Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amouni/Mo- M ` <br /> Ftorttetswaef.orRse> da��tt` atu c4rt �snhafotlouvtna-"Jcertifytha!in'heperformancenftheworkforwhichth'sspermitisissued,Ishallrote^sp4oyanype <br /> lrr Si�Ch'Trl�r�ei a";0 t18�C0iTtA� "tt'��Y�31'k ' :`:; ^:t%,^.f,�iSa�Ui•w'�:V5 I ra IMP <br /> C_nersctor hiring t�^bona }C ' � <br /> O: ciiog'. i e-,i`y:te;,n the perf0lll3^:CL'Oi 11P tidOrk tOr rltilCll ih!5Br mi"..is311 d,I shall -; <br /> errpio,%peI brig U3 juct to, <br /> f� <br /> I hereby certify that I have prepared this applteati n and that the;wo 11 <br /> k will be done in accordance with San Joaquin County .\ <br /> ordinances, state laws, a rules and regu ions`f4he San Joaquin--Local�Health District. <br /> APPLICANT'S SIGNATURE X fr <br /> v <br /> f k <br /> } s­4-. <br /> FOR DEPARTMENT USE ONLY t <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 8 Received By Jury 31 _� <br /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE- REM4TTED AMOUNT _ <br /> FEE ' m <br /> LESS--PRORATION- <br /> PLUS =. - <br /> `PRORATION - <br /> PLUS j' { <br /> PENALTY <br /> OTHER7, <br /> OTHER {, <br /> i ' € <br /> Received by Date-_�Receipt-No, -Permit No. ssuan a Date Mailed Delivere <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201K I <br /> r <br /> 4 1 <br />