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Applications Will Be Processed When Submitted Property Completed.tie pure 10.71911 1 ua wv+w�• <br /> APPLICATION <br /> - (For Non-Transferable,Revocable,and-Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT d <br /> LIQUID WASTE <br /> Appl!cation is hereb ade to carry on b einess in the"uri ictianal area of th" 1 Jo. uin Lgcal H alth Distri..t. I <br /> On Business Name (DBA) + -� � C1__Address <br /> - <br /> d Owner Address <br /> a <br /> u Firm Partners, Addresses and Telephone Numbers -" <br /> aBusiness Telephone No.— '' I%"y �� -- _ Emergency Telephone No. <br /> Contractor Licence No. <br /> � _._.... .__... Title <br /> M <br /> a Applicants Name <br /> (Print) . _,t Date - <br /> Please check Applicable Category(1-7)and Fill In the Requlredinformation V ' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June'30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) -- .... - °4 <br /> Serial No. f CAL.License No. ,._.... CAL.License Renewal No, _ <br /> Capacity '� "' Gat„Weights&Measures No.�i-- --.- - -- - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r4 �' <br /> • � } Heti' � �t • ,� .� � �i�. �`1 �y�' f,. �, ,• <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No-of Chemical Toilets Stored ` - <br /> 1 <br /> 3. ❑ PERCOLATION TEST s - <br /> '.R.S.or R.C.E.Name , t Rs—or.R.C.E.No. -- <br /> Test Location - Test Date/Tim� {. -- <br /> 4. 0ANITATION PERMIT <br /> Job Address/Location .-71-2 �"' ' - - , <br /> r„ <br /> Owner k R Address <br /> ❑ SEPTIC AN- ❑ CESSPOOL L�LEACHING.FIELD SEEPAGE PIT/ ❑-PACKAGE PLANT r <br /> PERMANENT 11 TEMPORARY C1 NEW WREPAiR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,,L June 30, 19 _ .� 'R a•' ' <br /> Type Construction `,_ ?� V Disposal Site__._. _. <br /> No.of Units <br /> Equipment Storage/Cleaning Locstion(s) <br /> 6. ❑-PACKAGE TREATMENT PLANT For Julyj,-June 30;19.-+' <br /> ,. <br /> Where Certified 5 , <br /> Operator Name - <br /> Plant Location -- <br /> Plant Capacity NQlUnit's°.Se7ved -- <br /> 7. ❑ LAUNDRY For July'l-June 30.19 <br /> i • "� <br /> SIZE: ❑ Less Than 1,000 Jq: Ft., ❑ More Th?n-T000vSq_Ft. k - <br /> ❑ DRY CLEANING,Chem icats�llsed/Amoi t Mo` - <br /> t •.• <br /> I hereby certify that 'have prepared,this•application and that t64 work will be dohs in accordance with San Joaquin County . <br /> ordinances,stela laws„�,,•and rules and,Legulatiorls'of`t SariJgagl�in Local Health District. � ; <br /> APPLICANT'S SIGNATURE X -- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PFR SITE ❑.EACH ❑ January 1&Received By January 31 ❑ July 1&Recew!!5raY July. 31 • <br /> _ ...-...._. <br /> EASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> ,�.t7ATE DA7.E :,.,F3EM1T?£D.,_. AM6UtV7 _ <br /> 1' FEE .. ' <br /> LESS py <br /> PRORATION _ 9999• ____.. - —._._. .. -- " ' <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER i c <br /> /j f tV s <br /> Received by i Date D [Rkeiptt No. 1 ermit No �ue - Mailed Delivered "1 <br /> APPLICANT—RETURN ALL COPIES TO. E14VIROMMENTAL HEALTH PERMITISERVIC•ES_ -�19ol E.HAZELTON AVE.,P.O,Box 2009 STOCKTON,CA 9520t <br />