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f <br /> Applications Will Be Pr. .ased When Submitted Properly Completed.Be sur: :sign I ne.+NNS..a.:..,,• i <br /> APPLICATION <br /> (For Mon-Transterabie,Reiocible,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> LIQUID WASTE <br /> Application is In b made to carry on business in the jurisdictional area of th an J aqu��cal Heaa District neo Business Name (DBA Address <br /> e Owner „.Address <br /> Firm Partners, Addresses and TIPlephone Numbers <br /> Business Telephone No. Emergency Telephone No: <br /> Contractor Licence No. , <br /> r-- <br /> Applicants Name(Print) . - Title STr�I ff�7C °�-_ Date -� <br /> Please check Applicable Category.0-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) ` <br /> Disposal Sites esFdr JulY 1, dune 30, 19 •.r R c - v� t <br /> Description(Make/Yr-,Color) i t <br /> a, <br /> � � - i <br /> Serial No. CAL. License No,-._ CAL, License Renewal NO.4 <br /> Capacity Gal.,Weights&Measures No_ <br /> 'Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, JLine 30,19 <br /> No. of Vehicles Stored `71 <br /> No. of Chemical Toilets Stared <br /> 3. ❑ PERCOLATION TEST ...- <br /> R.S,or R.C.E.Name R.S.or R.C.E.No_ <br /> 111 Test Location Test Date/Time <br /> 4. 99-TA—NITATiON PERMIT <br /> Job Add ess/Location494.4p, <br /> I Owner �'� � S Address. I W <br /> ❑ SEPTIC TANK ❑ CESSPOOL, 19'CEACHING FIELD } SEEPAGE PIT ❑ PACKAGE PLANT <br /> 3-'PERMANENT 137EMPORARI7�_ 132�NEW r REPAIR ❑ OTHER q( <br /> 5. ❑ CHEMICAL TOILETS For July 1~'June'30, 19 6` <br /> Type Construction- '>ry�' Disposal Site C <br /> Equipment Storage/Cleaning Location(s) t 6 <br /> No,01 Units , <br /> 6. ❑ PACKAGE TREATMENT PLANT—For.July 1!•June 30,19 ti I <br /> Operator Name Where Certified <br /> _; f•� , . �_ <br /> Plant Location <br /> Plant Capacity ; l y� No. Units Served <br /> t '` f <br /> + T. 0 LAUNDRY I For July,1,='June 30, 19 $ <br /> SIZE: 13 Less Than 1,000 Sq- <br /> 13 DRY CLEANING,Chemicals Used/Amount/Mo' T t <br /> IT <br /> r � <br /> I hereby certify that l h ve prepared this applicat" nd that the work will be done in accordance with 5an'Joaquin County <br /> f ordinances,state laws id les and ulatio the oa in Local Health District. <br /> 7( t <br /> .APPLICANT'S SIGNATURE <br /> i FOR DEPARTMENT USE ONLY �-Y <br /> Fee Is Due:© ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received 9y January 31 �:July t 8 Receivatl 8y July 31 <br /> } - REMIT <br /> r BILLING REMITTANCE S <br /> RASE E%PLANATION AMOUNT DUE CHECKED <br /> € F�,-k GATE DATE REMITTEq• AMOUNT <br /> FEE ; �` - 4 <br /> LESS I <br /> PRORATION . <br /> PLUS l � <br /> PENALTY <br /> OTHER <br /> � .OTHER � - -' - .. .i T •� t- I4 .. - __ .. � -,.. - _ <br /> ... r <br /> ,- Received by Date Receipt Na. Permit No. I i"uonci Dat M led Delivered y <br /> APPLICANT—RETURN ALL COPIES To: ENviRONMENTAL HEALTH PERMITISERVICES 16ot E.HAZELTON AVE.,P.O. M009 STOCKTON,CA 95201 <br /> +I <br /> 1 <br />