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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApPlicallion. - <br /> APPLICATION --"- <br /> (For Non-Transferable, Revocable, and Suspendable) \k!13 ID SEPTAGE P *� <br /> ENVIRONMENTAL HEALTH PERMIT ,�0 <br /> LIQUID WASTE G <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 6 <br /> r o 0 Address o 5 <br /> Address—/ S. C� E <br /> N Business Name (DBA) <br /> i Owner <br /> l d <br /> 9 Firm Partners, Addresses and Telepho a Numbers <br /> Emergency Telephone No. <br /> CL Business Telephone No. <br /> s Contractor Licence No. ^j <br /> Applicants Name {Printf T <br /> :�.+ /L/ / T Title T Date /.z <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 Disposal Sites <br /> r+ <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. —" CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. r ' <br /> j Equipment Parking Address <br /> I 2. ❑ PUMPER-YARD <br /> � <br /> ' r y;s , <br /> F For July 1June 30, 19 <br /> ,z t <br /> No. of Vehicles Stored ,f �-_:< -,.,; T. •x- * <br /> No. of Chemi alToilets Stored - <br /> . <br /> 3. 13 PERCOLATION TEST <br /> R.S. or R.C.E. Name a R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. X SANITATION PERMIT ' <br /> t Job Address/Location <br /> Owner I,/ h Address <br /> SEPTIC TANK ❑ CESSPOOL tZ LEACHING FIELD AQP SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY —0,REPAIR - ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq..Ft.,R ❑_ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a and regul ,O "s of the an Joaquin Local Health District. <br /> P <br /> APPLICANT'S SIGNATURE X <br /> �� <br /> I . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January.1 &Received By January 31 ❑ Juty 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S (C' Cl <br /> LESS t <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER <br /> F <br /> OTHER <br /> 3)I LI-7 j 10l <br /> Received by Date Receipt No. Permit No. issu nce Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 7601 E.HAZELTON AVE.,P.O.Box 2009'' STOCKTON,CA 95201 <br />