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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable;Revocable;and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> GZ LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Jo�qu' -Local Health District,. <br /> Addr �+ . 4 Hild.reth D�Lhd <br /> Business Name (DBA)_ Mina l d Septic $E �B�ckh-e ess-e ... _ <br /> cOwner..,. r r�•. ,. MC' T)on-ca I d -Address . <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business'Telephone No. - - Emergency Telephone No. 957 4:6!a27„ ' - <br /> ' ;Contractor Licence No. <br /> LApplicants Name (Print) T. R. —Mreal d x Title �1lTler Date <br /> Please check Applicable Category(1-7)"and,Fill in`the Required Information ,�F er,;. .r 40 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I A <br /> ' For July 1;- -'-'June 30, 19— Disposal Sites- <br /> Description(Make/Yr., Colony <br /> Serial No. CAL. License No. CAL. License Renewal;No. i <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address i iM <br /> ! 2. ❑ PUMPER YARD <br /> k For July 1, June 30, 19; <br /> No. of Vehicles Stored' <br /> 4 No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATIONTEST <br /> R.S.or R.C.E. Name ' _ _ R.S. or R.C.E.No. <br /> Test Location Test Date/Time T <br /> 4. ❑ SANITATION PERMIT I� <br /> Job Address/Loca 'o 4 <br /> Owner Address <br /> SEPTIC TANK- ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY .NEW ❑ REPAIR ❑ OTHER pC <br /> 5. ❑ CHEMICAL TOILETS For July 1,-Jur'e 30, 19 <br /> Type Construction t Disposal Site r <br /> No, of Units Equipment_Storage /Gleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name Where Certified <br /> Plant Location �p <br /> Plant Capacity No. Units Served <br /> ;7. ❑ LAUNDRY For'July 1, _June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <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, and rules and regulations of the San Joa in Local Health District. <br /> APPLICANT'S SIGNATURE Xpit- <br /> - <br /> FOR DEPARTMENT USE ONLY <br /> NIT ❑ PER SITE ❑ EACH ❑ Januar 1 &Received By January 31 - ❑ July 1. Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PERU Y r <br /> -__ .. - REMIT <br /> BASE EXPLANATION BILLING �, REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE 'REMITTED if AMOUNT <br /> FEE <br /> LESS _ 4� <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER L. <br /> OTHER h�I <br /> Received by Date Receipt No: Permit No. Issiliance Dalle Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />