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V ......IGU "-F—Y a.vn.r.c.ca.. ——. .v.aryn ...c _NN..a.v..a..r. <br /> APPLICATION / <br /> mar Non-Transferable, Revocable,and Suspenda SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT- <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> FBusiness m DBA _ Address <br /> z Owner7/ /t7f y Address <br /> I - <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> Q • n <br /> Applicants Name (Print) Title Date <br /> Please chett-Applicable Category(1-7)and Fill in the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites i <br /> Description(Make/Yr., Color) <br /> Serial No. —_ - CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights S Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored T <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 /> Test Location Test Date/Time <br /> 4. g SANITATION <br /> Job Addrtion <br /> Owner es o s Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> .PERMANENT ❑ TEMPORARY ❑ NEW REPAI E] OTHER Q <br /> 5. El CHEMICAL 70ILE'�S For July 1,-June 30, 1? n_ �� / <br /> Type Construction Disposal Sitey,( �{ _ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PAIJKAGt TREATMENT PLANT For July 1, -June 30, 19 _ <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <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. <br /> fror"ownferpr Ffc-,t^aed agent's ire i1ofllre cP,rtt;tes±F.3frllrwu;;1 �"I CPr1ifyth2?iRthe n�riprrl�n,rp of tho ti,�r?cf,r whit•h"���nerr^t'-I;iss','ed.?�:`'all not�Mnl�?uanr erse. <br /> 3l1 <br /> ;. <br /> Crt *ra-ac, - or F.,r <br /> Shall <br /> I hereby certify that I have prepared this application and that the work will be donb­iiri accordance with San Joaquin County <br /> ordinances, state and s anq regulatio f the San Joaquin Local Health District. <br /> IGNATU E X ,,/ ----- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE gREMITTED AMOUNT <br /> FEE — <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 1 <br /> OTHER---- ---- � � -- <br /> OTHER r } r <br /> Received by Date J Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN!ALL COPIES TO: ENVIRONMENTALIHE4LTH PERMIT/SERVICES 1601 E..HAZELTON AVE.,P.O.eoc 2009 STOCKTON,CA 95201 - <br />