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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION r <br /> (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> �.� ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID'WASTE <br /> w' Appl ication is hereby made to carry on busine4 in the jurisdictional area of ttje San Joaquinoca ealth District <br /> V r Business Name (DBA) `AddressLI V�fl <br /> z Owner I�1 Y -� , Address <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. g �^ Emergency Telephone No. <br /> Contractor Licence-No. . <br /> a s"I.. . . Title Date <br /> L Applicants Narrie {Print) <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, Y June 30, 19 Disposal"Sites - - <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. - ( CAL. License Renewal No. <br /> Capacity "Gal.;Weights-&-Measures-No-� =-,=-4---�&-_..y-- _ --- - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,—, June 30, 19 <br /> No. of Vehicles Stored u_ <br /> No. of Chemical Toilets Stored _ <br /> 3. ❑ PERCOLATION TEST t <br /> R.S.or R.C.E. Name <br /> R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT # <br /> r Job Address/Loc; t'o[I <br /> Owner_ "�t l 1 s Address <br /> F '. �. s <br /> @,e EPTICTANK ❑ CESSPOOL <br /> � LEACHING FIELD SEEPAGE PIT 0 PACKAGEPLANT ( � + �"�t <br /> ` <br /> PERMANENT ') ❑TEMPORARY i NEW ❑ REPAIR ❑ OTHER <br /> 5.jO CHEMICAL TOILETS ForsJul 1,-June 30, 19 f <br /> Type Construction y Disposal Site <br /> r <br /> { ) <br /> No.of Units Equipment Storage/Cieaning'Location(s) <br /> ". <br /> 6- ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name--- Where`Certified <br /> Plant Location <br /> ,:Plant Capacity No. Units Served, .. '�M` <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: El Less Than 1,000 Sq. Ft., 0 More Than 1,000Sq. Ft. �' f4,;-1 A ' <br /> f,'DRY CLEANING, Chemicals Used/Amount/Mo. P., �'� " ' ' r <br /> A4 r r y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> _7__ ordinances,. to d rules a regu tions o he Sa Joaquin Local Health"District. <br /> APPLICANT'S SIGNATU <br /> 1 <br /> FOR DEPARTMENT USE ONLY k ` i <br /> l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ; ❑ July 1 &Received By July 31 ' <br /> REMIT <br /> } BILLING REMITTANCE $ AMOUNT DUE CHECKED 1 <br /> BASE EXPLANATION DATE DATE REMITTED ' <br /> �j AMOUNT � <br /> FEE , T �� ��OC7 ... <br /> 1I LESS <br /> PRORATION: <br /> �.� PLUS <br /> PENALTY _ <br /> 4 OTHER <br /> OTHER <br /> /-.- <br /> Received by _.� Date Receipt No Permit No. Iss ante to Mailed Delivered <br /> t <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITY$ERVICES "'�' -'16D1 E.-HAZELT E.,P.O.Box 2009 STOCKTON,CA 95201 <br />