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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 hi�e--reby made-�to•�ca�,�( n busi s In,.th jurisdictional area oft San oaqu`in Lopal Health District <br /> rsusiness Name(DSA)i.,3..� ��� i C1�� •Address ! <br /> a Owner—L-� Address _ <br /> J.Firm Partners,Addresses a �jelephone Numb rs J y <br /> aBusiness Telephone No.. _�c ,S!c�- Emergency Telephone No. <br /> -i Contractor Licence No. <br /> L Applibants.Name(Print)=�.C�� -� L u _Title <br /> Please check Applicable Category(1-7j'and Fill in the Required Information.- <br /> 1. <br /> nformation-1, ❑ PUMPER,VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, s 'Jurte 30, 19 't— Disposal Sites <br /> Description(Make/Yr.,Color) _ t ►,� ..r . f: '.i <br /> Serial No. CAL.License No. + CAL-.-H66 se Renewal No, <br /> Capacity Gal.,Weights&Measures No. - ---•-_�'�" _ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER Y_ARa,-� <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored*^^"""r`� <br /> JNo.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 DateMme "t <br /> 14. ❑ SANITATION PER IT <br /> Job Address/L JtA <br /> O ,er Addiress ,__ , ; <br /> EPTIC.TANK' ,❑' CESSROOL' t V---LEACHING Fittli ❑ SEEPAGE PIT ❑"PACKAGE'PLANT' <br /> PERMANENT /❑ TEMPORARY NEW 1 13T1EPAIR 13OTHER <br /> 13 CHEMICAL TOILETS For July 1,-June 30, 19 r <br /> pe Construction Disposal Site int <br /> -..10.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 - <br /> Operator Name - Where Qertified <br /> ,Plant Location <br /> ._:1 ,Plant Capacity No.Units Served I <br /> •. <br /> -7. ❑ LAUNDRY For July 1, -June 30, 19 — {-_ -# ;'"' ' <br /> T <br /> SIZE: ❑ Less Than 1.000 Sq. Ft., ❑ More Than 1,040 Sq. Ft. _ a <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certi ve prepared this plication work will be done in accordance with Lan Joaquin County <br /> � ordinances,St a laws, d s an r ul tili ns; etn'Jin Local e_alth District. ` <br /> f <br /> APPLICANT'S SIGNATURE X <br /> Ar ca <br /> FOR DEPARTMENT USE ONLY- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C1 January 1&Received By January 37 ❑ July 1 8 Received By July 37 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION '•*AMOUNT DUE CHECKED <br /> DATE- DATE REMITTED t ;° AMOUNT <br /> -PEES.-�•-,w...r .��.7,.i ......�;e, .-.--:+.+�.��-+,.-�- ar.�"3`'�,/ •�.Ir. �... ..`� . <br /> PLESS <br /> RORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER \� + <br /> Received by—. t Rec�ipE Permit N0. Issuance ate Melted DdIivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PFRMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 9it r <br /> LO/ <br />