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Applications Will Be Processed When Submitted Properly Completed. Be Sure o Sign The Application. 0 <br /> APPLICATION e / <br /> (F*n-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hgreby made to��nn business in the jurisdictional area of the Sa aquin Local Health District <br /> e ! / Address �"'Di !3 //y.'r'WyMc A <br /> n Business Name (DBA)0__ t —r <br /> i Owner aOdd- /�4-4:-�—� Address <br /> c' Firm Partners, Addresses and Telephone Numbers <br /> iBusiness Telephone No. - 49�1 "i� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ,0gf -z U4gTitle _��L t/� Date <br /> Please check Applicable Category(1-7)and Fill Irl the Required Information - <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, _ June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. _ CAL. License No. CAL.License Renewal No. <br /> Capacity Gel.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 1' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored , <br /> 1 <br /> 3. ❑ PERCOLATIONTEST <br /> A- <br /> .&-&R.C.E N@irie`. '— ---- —..— - - R.S.or RC.E. No. - - - - <br /> Test�L,oc tign Test Date/Time <br /> 4. NITATION PERMIT 0L,.pr' aa�i� <br /> Job Address/Loc 'on � �S �T� <br /> Address -147 IC- 7� s 7- <br /> SEPTIC TANK ❑ CESSPOOL" ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT r . p, <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For duly 1,-June 30, 19 <br /> Type Construction ) /Disposal Poi- <br /> No. of Units A Equipment Storage/C leaning,Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For JVIy.1,-June 30,19 ' <br /> Operator Name I. Where Certified <br /> Plant Location ' �•' <br /> Plant Capacity. /% 'f'' No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June130,'% - - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft..': ❑'More Than 1,000 Sq. Ft. <br /> 13DRY CLEANING,Chemicals Used/Amoun o. <br /> I <br /> I hereby certify that I have prepargd this application andothhaa) the'work Will be done'.lrr accd�dance-with S�mJopc;uin �ounty <br /> ordinances,state laws,ana rules e d uta sof h SenJoaquln Loce�Health District. <br /> APPLICANT'S SIGNATURE X � ) <br /> 74 <br /> \ ' • ,`,FOR-DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT 13 PER$ITE` ❑ EACH. ❑ January 1 A Racelved By January 31 ❑ July 1 a Received By July 3I I <br /> 4 i. / --BILLING REMITTANCE- s <br /> REMIT 6 <br /> BASE �.; .gXPLANkIrIbN,t i DATE•.",' DATE EMITTED ' AMOUNT DUE CHECKED <br /> 4\ I {• AMOUNT <br /> LIS - i m S <br /> FEE yy <br /> LESS <br /> PRORATION '4 - <br /> -PLUS <br /> PENALTY 'y <br /> OTHER <br /> OTHER �• �j 9 <br /> Reoeneci by Date Re ipl No. Permit No. yuan Dae Maded Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,D.O.Bax 2009 STOCKTON,CA 95201 <br />