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z <br />I <br />—� <br />Applications will Be Processed when Submitted Properly ae ,urc ry -,n - <br />�'` n <br />(For Non—Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />u4UID WASTE <br />I Applicata Is h reby ade to carry on buss s in the jurisdictional area of the o for cal Health����District� <br />rBusiness Name (DBA) <br />�� � rrtS ^�� ��S s Address L.7Cu,] '� <br />Address <br />Owner <br />— <br />Firm Partners, Addresses and -Tele hone liumbers Emergency Telephone No. <br />aBusiness Telephone No. <br />-J Contractor Licence No. Title --- Date - <br />i a Applicants Name (Print) <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -- <br />For JLily 1, __-June 30, 19 II Disposal Sites <br />Description (Make/Yr., Color) _- CAL. License Renewal No. <br />Serial No. CAL. License No. <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 />t No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST 11 R.S. or R.C.E. No. __.-- <br />R.S. or R.C.E. Name Test Date/Time <br />Test Location _ <br />4_ K SANITATION PERMIT C, <br />I Job Address/Loc lion <br />Owner _ Wr Address <br />❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br />�J SEPTIC TANK ❑ REPAIR ❑ OTHER <br />PERMANENT ❑ TEMPORARY 2t NEW <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />I Type Construction Disposal Site _ - <br />No. of Units !I -Equipment Storage/Cleaning Location(s) _ <br />.6. ❑ PACKAGE TREATMENTI"PLANT For July 1, -June 30, 19 Where Certified <br />Operator Name „fit <br />Plant Location r <br />No. Units Served <br />Plant Capacity - <br />7. ❑ LAUNDRY For July 1, = June 30, 19 <br />SIZE: C] Less Than 1,000 Sq. Ft., <br />❑ More Than 1,000 Sq. Ft. <br />r ❑ DRY CLEANING, Chemicals Used/Amount/MO. — <br />II <br />Joaquin County <br />I hereby certify that I have prepared.this application and that the work will be done in accordance with San <br />ordinances, state laws, and r es and regulationrohe San Joaquin Local Health District. <br />laws, <br />4F _ <br />APPLICANT'S SIGNATURE XC, <br />n <br />I <br />I. <br />I <br />O <br />I <br />L� <br />:W <br />V <br />— 1 <br />j <br />ice¢ I <br />! <br />FOR DEPARTMENT USE ONLY <br />❑ SITE C3 EACH ❑ January 1 & Received ny January 31 ❑ July t d <br />Heceiv <br />REMITuIy �t <br />Fee Is Due: ❑ ANNUALLY, <br />13 PER UNIT <br />PER <br />13ILLING REMITTANCE ; <br />AMOUNT DUE <br />CHECKED <br />BASE EXPLANATION <br />DATE DATE REMITTED <br />AMOUNT <br />I <br />�s cJ p <br />(J U <br />FEE <br />b- <br />' <br />LESS. <br />PRORATION <br />_ - <br />PLUS <br />PENALTY <br />a <br />✓ ( N <br />OTHER <br />OTHER <br />47,,f 7v5 Mailed Delivered <br />Received by <br />rDa1e Receipt No. Permit No. _ Issuance Date <br />RETURN ALL TO: ENVIRONMENTAL HEALTH PERMIT/SER1rICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 9510 <br />— APPLICAM—RECOPIES <br />