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nFrF.rw Vo •Fur uc V'WV 70cV ..IICI1 JMVIIMLWU rIVFJ y vV111FsIo\C V. D6 uulC IV olyn Inc r+}�F.rua.o.wrr. <br /> FAPPLICATION <br /> ' :. <br /> (for Non-Transferable, Revocable,and SuspendabielSEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> F k <br /> Application is h y ma a to car o usiness in the jurisdictional area oft San J aquin Local Health District <br /> FBusiness Name (DBA)., Address � � <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> EL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title zfrt-'-Please check Applicable Category (1-7) and All in the Required Information <br /> i <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. <br /> CAL. License Renewal Na. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address x" - <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 fi r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 3 SANITATION PERMIT f - <br /> Job Addre,s s'/Location � � � [G <br /> Owner 41 Addresst m+ <br /> SEPTIC TANK El CESSPOOL R,LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT w <br /> RIPERMANENT ❑ TEMPORARY E?�ONr W s ❑ REPAIR ❑ OTHER =� <br /> 5. ❑ CHEMICAL TOILETS For July-1, . 4 3b;113'_' <br /> 9_ <br /> Type Construction Disposal Site r <br /> No. of Units t Eq ipment Storage/Cleaning Location(s) <br /> 6. Q PACKAGE TREATMENT PLA f or July 1,-June 30, 19 , <br /> Operator Name r- Where Certified <br /> Plant Location <br /> Plant Capacity No. Unit,Served <br /> 7. © LAUNDRY For July 1,-June 30,--9- __..._�._.. <br /> I SIZE: © Less Than 1,006 S%:'Ff,: © More Than I,,000 Sq. R. <br /> 0 DRY CLEANING, Chemicals Used/Amount/Mo. `+- <br /> ss X <br /> I hereby certify that I have �gpa�ed &s a plication and t t the work will be done in acca nce it an Joaquin County <br /> '.' <br /> �, ordinances, state laws, g tions of the Joaqu'n Lo I He th District. <br /> APPLICANT'S SIGNATUREX "" <br /> FF' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receiveq By J n 31 ❑ July F1 &Re9eived By July 31 <br /> t. r REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE pE D AMOUNT DUFF"- � CHECKED <br /> AMOUNT <br /> FEE �0�.._ S2 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY -t �? <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Issuarice Dilite Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />