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APPLICATION <br /> -TI (For Non-Tran storable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appiica ion is her+�yb made to c r n usiness in the jurisdictional area of n J quin Lo 1 Health ct ? !' <br /> F Business Name (DBA) �j•F,• N21ZS i�} Addressf"• `k � rv �1 <br /> Owner _ _ Address <br /> Firm Partners, Addresses and Tele hone Numbers _ <br /> eBusiness Telephone No. `i�pL(i' 9!:% 7 Emergency Telephone No. <br /> Contractor Licence No. z- —4.,lr <br /> L Applicants Name (Print) � �I-- ~� �lCs Title A)A146 ., Date JZ" <br /> Please check Applicable Category (1-7)and Fill in the Required Information al" <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. 6 <br /> Capacity Gal., Weights & Measures No. ,. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 _ <br /> No. of Vehicles Stored <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. <br /> Testa Location _ Test Date/Time <br /> 4. Cl SANITATION PERMIT <br /> Job Address/Location ._ .A <br /> Owner —h as) ' >i� YAdd er ss_ 'S jJU�" <br /> SEPTIC TANK C3 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units _ — Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19— — <br /> Operator Name -_--------_�---_— ---�— -- -------_---_-_--i� -- Where Certified <br /> Plant.Location <br /> Plant Capacity_ _ No. Units Served �J <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> �V <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws <br /> ad r.ie§,and regula 'ons of thean)Joaquin LoralHealth District. <br /> APPLICANT'S SIGNATURE X <br /> r u. kJ <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> ---- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 4011 E.HAZELTON AVE.,P.O.Bost 2000 STOCKTON,CA 06201 <br />