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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 /> f ENVIRONMENTAL HEALTHRERMIT <br /> LIQUID WASTE <br /> Application is hereb made to carryon business in the.jurisdictional area of the San Joaquin Local Health District <br /> ,AR 1 Address <br /> y Business Name (DBA) Z�1 <br /> z Owner Address <br /> a s - � <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. ���� » - Emergency Telephone No. T <br /> Contractor Licence No. , <br /> Applicants Name (Print) SIA.4 S _'Title ' , Rate:- <br /> Please check 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- x Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. r CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> } <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July <br /> No. of Vehicles Stored - { <br /> No. of Chemical Toilets Stored i <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. O'%ANITATION PERMIT <br /> Job Address/Location Y S <br /> Owner � 1C �P_�} 'r' Address <br /> i� SEPTIC TANK ❑ CESSPOOL O-LEACHING FIELD EPAGE PIT 0 PACKAGE PLANT <br /> ®PERMANENT I] TEMPORARY 0 NEW REPAIR ❑ OTHER <br /> I� iia,- <br /> 5. ❑ CHEMICAL TOILETS For July@1``J;i ne 30, 19 f <br /> I <br /> Type Construction ,` Disposal Site <br />-,..Type <br /> .54 % . _ „ 'Equipment Storage/Gleaning Location{s) Tpl <br /> 6. 17 PACKAGE TREATMENT PLANT. For July 1, -June 30, 19 <br /> Operator Name 1 '-r� \ - Where Certified <br /> Plant Location <br /> Plant Capacity . � �� � No. Units Served }' <br /> � <br /> l <br /> 7. ❑`L'AU.NARY'"'ForJuly ��Junej30,119"_r- �% <br /> SIZE: - f©Les5`Tha1,, 00 Sq�ft. ❑'`More}Than 1,000 Sq. Ft. <br /> 14r'.DRY CLEANING, CheiXaisUssd/Amount/Mo.t(�"' .. <br /> hereby ce#`ify ia't"I'h—ave 'tbpared this applicatiaf� and that the w-rk will be done in accordance with San-Joaquin County' <br /> ordinances, state laws, les and reg ions of thk n Joa ocal k, <br /> ealth District. € , <br /> ' f <br /> APPLICANT'S SIGNATUREX {{;• - �_, _ W,. - FOR DEPARTMENT USE ONLY <br /> ,rr t � <br /> Fee Is Due: 13 ANNUALLY 1:1PE UNIT ❑ PER SITE 13 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ! .;-.. .... - REMIT <br /> BASE 1 EX LANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> C fs DATE DATE REMITTED AMOUNT. <br /> s i f b� 41 h <br /> FEE r <br /> LESS k <br /> PRORATION <br /> PLUS <br />`�. PENALTY - <br /> OTHER - t # <br /> i OTHER r �s _asst.{�� s �' 'IN t <br /> t`6Received by Date Receipt No. Permit No- I5sua e D Mailed Delivered t <br />�„�: 'APPLICANT—RETURN ALL COPIES TO: •ENVIRONMENTAL HEALTH PERMITISERVICES 11 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,PA 65201- . <br />