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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocable,and Suspendable) SEPTAGE= <br /> ` `� ENVIRONMENTAL HEALTH.-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the•jurisdictional area of the a San Joaquin,Local Health District..,., ' :r <br /> m Business Name (DBA) c_=en/ Address S• MA A4 5_,- - <br /> z Owner -Address - <br /> cl Firm Partners, Addresses and Telephone Numbers <br /> 5. Business-Telephone No. 1F « Emergency Telephone No. <br /> Contractor Licence No. f .5 <br /> Applicants Name (Print) Title 10 Date /d- <br /> -� <br /> Please check Applicable Category(1-7)and Fill inAhe Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ' <br /> For July 1,- June 30, 19 — 'Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. r, CAL. License No. CAL.s License Renewal No. <br /> Capacity' Gal., Weights & Measures No. <br /> Equipment Parking Address ' • r,t r' Tp �` <br /> 2. ❑ PUMPER YARD.-. <br /> For July 1, • June 30, 19 <br /> No. of Vehicles Stored '"� w �•`. .- <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST *" <br /> R.S.or R.C.E. NameR.S. or R.G.E. No. <br /> Test Location _ Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location,I7 r- ,AU Ab L It/D e f A <br /> ner a�ASS/ Address <br /> SEPTIC TANK C7 CESSPOOL V LEACHING FIELD .SEEPAGE PITA ❑ PACKAGE PLANT' _ <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ' ❑ OTHER .moi <br /> 5. ❑"CHE�CA"E TOILETS For July 1,-,June 30, 19 _ 41- <br /> Type <br /> Type Construction Disposal Site <br /> No of Units " *-•� w.Equipment-Storage/Cleaning-Location(s)»-- - rr <br /> 6. ❑ PACKAGE TREATMENT PLTCNT For July 1, -June 30, 19 � t VC <br /> E Operator Name ' '' .E Where Certified <br /> Plant Location i <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&mount/Mo. <br /> �, - __ .. j .�..,a•,a.---mow:..,-- ,,.. � ,.; -� �-•...�.:..� - <br /> I hereby certify that I have prepared this application and that the work.will-be,done in'accordance with San Joaquin County <br /> s ordinances, state laws,.and rules and regulations of the S Joaquin Local Health District, t• . <br /> APPLICANT'S SIGNATURE X <br /> 4•f � , <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY_ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> ' BASE EXPLANATION AMOUNT DUE CHECKED <br /> k DATE •* DATE REMITTED { AMOUNT <br /> FEE 3ig <br /> Y C Q <br /> I LESS ILII c� <br /> PRORATION ' <br /> PLUS - <br /> PENALTY <br /> OTHER , <br /> OTHER - - <br /> -•I Received by sr Date i rReceipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />