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Applications Will Be Processed When SubmiRted Property omp e <br /> APPLICATION <br /> (For Non-Translerable,`Rerocehie','and 5uspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTI!,PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin cal Health District <br /> SGr� S :Address <br /> NBusiness Name (DBA) Address 1 _ <br /> aOwner <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No;r • >� <br /> IL <br /> Business'Telephone No. <br /> _JContractor Licence No. . Title ��r_ Dat - <br /> rtsl <br /> L Applicants Name,(Print) <br /> Please cfieck Applicable Categoryn{1 7) and Fill in the Required,Information y .° <br /> 1. <br /> [I PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, = <br /> -Julre'30;i9 Disposal Sites { <br /> Description(Make/yr., Color) _ CALkicense Renewal No. <br /> CAL. License No, <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD. <br /> For July 1, <br /> June 30, 19 <br /> - <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST # <br /> R.S. or R.C.E. No. <br /> t 4 R.S. or R.C.E. Name <br /> Test Date/Time <br /> Time <br /> +Test Location - ` <br /> 4..A SANITATION PERMIT 112 N <br /> IN <br /> 01 of <br /> 1 ;Job dress/,Location <br /> Ad <br /> f.�. r „ Address <br /> yOwner'` ❑ PACKAGE PLANT <br /> 4. SEPTIC TANK. ❑ CESSPOOL,- V LEACHING FIELD JK SEEPAGE PIT ❑ OTHER <br /> ` ❑ TEMPORARY � NEW ❑ REPAIR " <br /> 99 PERMANENT 'F' ; i✓ <br /> 5• [3 CHEMICAL TOILETS For July 1~- <br /> June'36,19 e.�f 5A <br /> Disposal Site A <br /> Type Construction <br /> F ¢ � <br /> Equipment Storage/Cleaning Location(s)' 4 <br /> No. of Units 4 1 <br /> .r i '...i. a. <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1,-June 3019 Where Certified. . <br /> Operator Name <br /> r Plant Location No. Units Served <br /> i <br /> Plant Capacity r <br /> t r . <br /> 7. ❑ LAUNDRY For July 1,-June 30;,19 ' <br /> ❑ Less Than 1,000 SFt., <br /> []-,More Than 1,000 Sq. Ft. <br /> SIZE: q. ...•- , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �. <br /> lication and that the work will be done in accordance with San Joaquin County ; <br /> I hereby certify that I have prepared this app ' <br /> ordinances, state laws, and rules and regulations San Joaquin Local Health District. <br /> Of <br /> APPLICANT'S SIGNATURE X } <br /> FOR DEPARTMENT USE ONLY r �� <br /> } , ❑ January 1 &Received By January 31 El July 1 &Received By JUIy 31 -. <br /> Feels Due:'❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACN - REMIT <br /> $ AMOUNT DUE CHECKED ° <br /> BILLING REMITTANCE AMOUNT <br /> BASE EXPLANATION DATE .DATE REMITTED-- <br /> FEE <br /> LESS <br /> PRORATION .-. <br /> Y' <br /> V PLUS <br /> i PENALTY <br /> OTHER <br /> 1 OTHER <br /> 4 <br /> _ - r' ;. -:-'- Mailed .-Delivered <br /> Receipt No. Permit o. •.Issuance Dates <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 9201 <br /> t <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICE .y 1'F`�, tea z <br />