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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is eby.made to rry n b ess i th 'urisd' tional area of the San aquin Address <br /> Lo aI Health District <br /> yBusiness Name (D ) <br /> z Owner Address <br /> a <br /> 7 Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. / -� Emergency Telephone No. <br /> a �y� <br /> Contractor Licence No. Date <br /> Applicants Name (Print) Title <br /> Please check Applicable Category (1-7) and Fill in the Req Ired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 'I , Disposal Sites <br /> For'luy 1, Ju—unene 30, 19 <br /> Descriptio_n(Make/Yr,Color)t <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights &.Measures No. <br /> Equipment Parking Address I )f <br /> 2. ❑ PUMPER YARD 1 t <br /> I • <br /> For July 1, June 30, 19 k <br /> No. of Vehicles Stored ' 'f <br /> No. of Chemical Toilets Stored <br /> t � 1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name � <br /> Test Location <br /> Test Date/Time I <br /> 4. Ls SANITATION PERMIT <br /> Job Address/L atjon %2��A�� A <br /> Ow r ss ' <br /> C� ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> t,4;SEPTIC TANK POOL ,�`� ❑ OTHER <br /> 90 <br /> G PERMANENT ❑ TEMPORARY NEWS ` ❑ REPAIR <br /> I_ . <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,'119 i <br /> Type Construction I:Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified, <br /> Operator Name <br /> Plant Location F. . + <br /> Na. Units Served <br /> Plant Capacity _ <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. 1 r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance Sa.n,J�oaquin County <br /> ordinances, state laws, and rules and XItions ofthe San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE El EACH ❑ J nary R MIT <br /> q eceiv d By January 31 El July 1 &ReceivedJuly 31 <br /> BILLING REMITTAN $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE D TE REMITTED AMOUNT <br /> r <br /> FEE 41 <br /> LESS - <br /> LESS <br /> I PRORATION <br /> PLUS { <br /> PENALTY <br /> j OTHER <br /> OTHER <br /> I Received by - Date Receipt No Permit NoIssu n e Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON;C 95201 <br />