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�» Applications Will Be Processed When Submitted Properly Completed Be sur} iObig e!+PP1rcauaIN <br /> ° APPLICATION <br /> �-+ (For Non-Transferable, Revocable,and Suspendable SEPTAGE <br /> ENVIRONMEMA—FIEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h reby made to carry o business in the jurisdictional area of ihe.San Joaquin Local Health District <br /> fi Address.r� �� <br /> F Business Name (DBA) •• <br /> i Owner a �-� a. Address <br /> J Fiv Partners, Addresses and Telephone Numbers <br /> 0. .� Emergency Telephone Ido.. , <br /> 0. Business Telephone No.' - � _ �.::. � � �--- - ,- - - - <br /> Contractor Licence No. t ti <br /> �-L�2 Title Date. <br /> L Applicants Name (Print) <br /> 'Please check Applicable Category(1-7)and fill In the Required Information ., � O „ ,>( ,O.e,�,> 4 <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Sites <br /> Disposal _ - <br /> For July 1, .. June 30, 19 - " .rte_.- p osal - .. .. _ <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License Na. CAL. License Renewal No. <br /> Capacity Gal.-'Weights &Measures No. <br /> Equipment Parking Addressp <br /> 2. ❑ PUMPER YARD + . % _ <br /> For July 1, "" June 30, 19 f' � . % <br /> No. of Vehicles St6red <br /> No. of Chemical Toilets Stored r y <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> 'Test Lo tion Test Date/Time <br /> F ,�, 3 r <br /> 4. I(J SANITATION PERMITCA <br /> /' L � .�.e.fes, �"�T • <br /> Job Address/Locats•ion <br /> Mt Address' ; <br /> Owner <br /> r / LS LEACHING FD, e❑ EEPAGE PIT ❑ PACKAGE PLANT i <br /> SEPTIC TANK CESSPOOL IEL <br /> 1:1 PERMANENT ❑ TEMPORARY ❑ NEW 1 -REPAIR ❑ OTHER <br /> M <br /> -#Ar <br /> 1 r r ) <br /> 5. Q CHEMICAL TOILETS For July -June 30 19y ( 4 �. <br /> Type Constructiori Disposal - ' t <br /> INo. of Units. . Equipment Storage/Cleaning Location(s) t t <br /> 6. 1:1PACKAGE REATMENT PLANT For July 1, -June 30, 19 <br /> r a Where Certified [ <br /> !OperatortNam t <br /> Plant Location _ <br /> Plant Capacity y No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 3019. - `. -----^""- <br /> 'SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More„Than 1,000 Sq. Ft. <br /> 5 DRY CLEANING,Chemicals Used%Amount/Mo- y <br /> here]iy certify that I have prepared-this.appltication and tr—N_Qhe work will bezion'e in accordance with San Joa in County <br /> ordinances, state-iaws, and'rules and regulati sof he San Joaq"uin Local Health District. -�` <br /> (APPLICANT'S SIGNATUREX '~ *l Y �- <br /> l S e .FOR DEPARTMENT USE ONLY + <br /> Fee Is Due:'❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE _. ❑ EACH. '❑ January 1 &Received By January 37 ❑ July 1 &ReceivedREMIT <br /> uIy 31 t 'z <br /> 'BASE , EXPLANATION' BILLING E REMITTANCE $ r AMOUNT DUE CHECKED <br /> ' <br /> DATE DATE REMITTED ........AMOUNT•-�-•—� <br /> LESS i - <br /> PRORATION �J!' <br /> PLUS <br /> I PENALTY' ? <br /> ZOTHER <br /> ft <br /> OTHER ;a.F ,� -;..�-.s--,- �.�.....+;:=a. _-_• 4..... - - - . <br /> t Receivedyby Date Receipt NO. Permit No. I nce ate Mailed Delivered <br /> 4. 1 ySTOCKTON . <br /> APPLICANT-t <br /> RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE$ 1601 E.HAZELTON AVE.,P.O.Box 2009 ,CA 95201 <br />