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Applications Will Be Processed When Submitted Properly Completed. Be sure 1o71gn I'it!MPIP11— <br /> APPLICATION <br /> (For Non-Transferable, Reiiocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional,area of th an Joaquin Local Hea District <br /> /�� �yf�. <br /> rBusiness Name (DBA)���--l=�i� � Address <br /> Address <br /> a Owner <br /> Firm Partners, Addresses and�T�ele,p/h�o,.,ne Numbers <br /> C11 Business Telephone No. ''I'll <br /> ~��Q Emergency Telephone No: _ w <br /> Contractor Licence No. -Z <br /> Title Date, <br /> Applicants Name (Print) Date, <br /> Please check Applicable Category(1-7)and t=ill in the Required Information .:. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) x <br /> For'July i, June 30, 19 - Disposal Sites _ <br /> Description(Make/Yr., Color) A <br /> CAL. License No. CAL. License Renewal No.'. <br /> Serial No. ' <br /> Capacity Gal., Weights & Measures No. a <br /> "Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ,E <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST .- <br /> R.S. or R.C.E. o. <br /> R.S.or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. 94-fA-NITATiON PERMIT f <br /> Job Address/Location !reyt� <br /> Owner!':'. a %L; iiAddres,�s9! U d <br /> ❑ SEPTIC TANK ❑ CESSPOO 'CEACHING FIELD M��`SSEEPAGE PIT ❑ PACKAGE PLANT <br /> 19-PERMANENT ❑ TEMPORARY,., ❑ NEW t * EREPAIR ❑ OTHER # a� <br /> ❑ CHEMICAL TOILETS For July 1,N'June'30, 19 <br /> 5. _ C <br /> Type Construction- <br /> r '`e "" Disposal Site 6 <br /> No. of Units Equipment Storage/Cleaning Location(s) $ k . <br /> 6. ❑ PACKAGE TREATMENT PLANT -For,July 1`-June 30, 19 k <br /> Where Certified: 1 <br /> Operator Name <br /> Plant Location <br /> Plant Capacity ! No. Units Served s ` <br /> 7. ❑ LAUNDRY " For July 1, -..June 30, 19 y <br /> SIZE: ❑ Less Than 1,000 Sq, Ft., 11More:fihan 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo:' <br /> , <br /> *" C <br /> I hereby certify that I h ve prepared this applicat'iu. nd that the work will be done in accordance with San <br /> 'Joaquin County <br /> ordinances, state laws d rules and ulatio the oa in Local Health District. <br /> APPLICANT'S SIGNATURE <br /> a . j <br /> FOR DEPARTMENT USE ONLY • <br /> t <br /> Fee IS Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 E fl.:July t &ReceivedREMIT ByJuly31 <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> c DATE DATE REMITTED AMOUNT <br /> BASE EXPLANATION <br /> F.. <br /> FEE Cl �'� - - '• - -. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> :-,..OTHER _ .. "d' r• n �z i, / F. <br /> r b63 <br /> Received by <br /> ry Date Receipt No. Permit No. lssuanc Dat M 'led Delivered .may <br /> 1801 E.HAZELTON AVE,.P.O. o.2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />