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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> APPLICATION <br /> w' (For Non-Transferable;Revocable,.and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 't <br /> Application is reby made carp�pn usiness in the-jurisdictional area of the San Joaquin Local Health Distric/ <br /> y Business Name (DBA} Address Z�26.' �� h4tr✓ <br /> aOwner _ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. N _ _y Emergency Telephone No. <br /> A Contractor Licence No. ' <br /> L Applicants Name (Print) n -Title <br /> .v Date <br /> l <br /> Please check Applicable Category (1-7)and Fill in the Lquired Information.,,.- <br /> 1. <br /> nformation,l 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June-30,19, : T. : -Disposal Sites- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity` - f Gal", Weights&Measures No s <br /> Equipment Parking Address r L t , <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> ,No. of Vehicles Stored <br /> No" of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name a R.S.or R.C.E. No. <br /> Test Location Test pate/Time <br /> 4. l�'SANITATION PERMIT <br /> Job Ad hi.,A y—. p ' ddb <br /> Owner T T Address <br /> SEPTIC TANK ❑ CESSPOOL �LEACHING FIELD '$EEPAGE PIT ❑ PACKAG PLAT <br /> �RMANENT ❑ TEMPORARY NEW ❑ REPAIR .❑ OTHER \ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction a Disposal Site <br /> _No. of Units Equipment Storage/Cleaning'Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location ' <br /> , r <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19-- <br /> SIZE: <br /> 0, 19-SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t e <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will 6e done in-accordance with San Joaquin County <br /> ordinances, state laws, and rule .a49d regu tions ofth San Joaquin Local H .Ith District. <br /> APPLICANT'S SIGNATUREIX <br /> d —FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH-� ❑ January'l &Received By January 31 ❑ July 1 &Received By July,31 <br /> REMIT <br /> BASE EXPLANATION BILLING = REMITTANCE $ AMOUNT DUE CHECKED <br /> - -- DATE- DATE REMITTED - - AMOUNT- r <br /> FEE a. 3 �• TtJ - <br /> L ryry,, <br /> LESS ��9\ <br /> 'PRORATION - s <br /> PLUS - ' <br /> t PENALTY ---f' - - - <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No. Permit No - Issuarice Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES.. '"`1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br /> Jf-d J( J �� <br />