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APPlicauon <br /> Applications Will Be Processed When Submitted Properly Completed. Be SureToSignThe <br /> APPLICATION <br /> (For Non-Transferable;Revocable;and Su spendable) SEPTAGE <br /> zr ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on b siness in the jurisdictional area of the San Joaquin.Local Health District ems,4 <br /> m Business Name (DBA).�� �� js - Address <br /> ,. <br /> 1- Address <br /> z Owner. ; R �� . .� t •.. i� •� . <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL O Emergency Telephone No. M 4 <br /> M Business Telephone-No. -f . + . <br /> a Contractor Licence No. a>. O� <br /> Applicants Name (Pring�' ,_C/ � , � Title to Date n 3 <br /> Please check Applicable Category(1-7) and Fill In-the Required lnforniation . i #�1 .„t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, w June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) Y r <br /> Serial No. `CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address ,. . .._.� ,... ..-... <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 .' <br /> b 1� <br /> No. of Vehicles Stored <br /> ' No. of Chemical Toilets Stored '. <br /> i 3. ❑ PERCOLATION TEST <br /> --R:S.-or R.C.E.No. <br /> R.S. or R.C.E. Name _ . <br /> Test Location. Test Date/Time <br /> I C X SANITATION PERMIT <br /> l Job Address/Location <br /> Owner Address <br /> 21 SEPTIC TANK 11 CESSPOOL ® LEACHING FIELD 19 SEEPAGE PIT 11 PACKAGE PLANT <br /> 13PERMANENT ❑ TEMPORARY 13 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r Disposal Site <br /> Type Construction <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 t <br /> Plant Location _ - <br /> No. Units Served F_ T <br /> Plant Capacity ' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> � <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑,MoreThan 1,000 Sq. Ft., � µ �_ „rr"' • � <br /> ❑ DRY CLEANING,`Chemicals Used/Amount/Mo., r. <br /> I` p r <br /> r Home ownerorficonsedagrmt's5ignal-e car'WiOtzxile't-ilntteinn "Ir,Ntifythaf ntheperforr-nanreo thn:+; rl;icrr.-hicfithisperrritisissued,lszzlinate�trloyanyper,.n <br /> } in such manner as to becn,ne sutiect"C'"� k n a s r.zllmlc, ?,IGn latus o°r lifcnl= , <br /> Contractor's.hiring.or sub-contranAla 1 S�iy�tur^:cess ' the n' l0Wh,._g "I Curtliy tl'a;in 11"r,pEi#Grrlu'tC_of ti,9'dJ0 4 for N�hlCtl li S pCYSllii iS iSSueG,I shall <br /> employ persons subject to wolf ari s eul'ipcon <br /> nsmaa da:ys 3«Ga +<ia,:., �. --• t ^ <br /> t <br /> I hereby certify 'that I have prepared this application and that the work will be done in accordance lith San Joaquin County <br /> ordinances, state laws, and rules and regulations of San Joaqu Local Health Distri h <br /> APPLICANT'S SIGNATURE X <br /> - <br /> - _. .fFOR DEPARTMENT USE ONLY " e— <br /> Fee is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH El January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ - - REMIT <br /> E ; BILLING HEMITTANCE - $ <br /> } BASE - EXPLANATION AMOUNT DUE CHECKED <br /> } ` DATE. DATE REMITTED AMOUNT <br /> FEE # 5 LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> . .. F7U ./ <br /> P <br /> Received by Rate 'Receipt No. ermit No. esu a Date Mailed DeNvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES"- 1601 E.HAZELTON AYE.;'P.O.Box 2009 STOCKTON,CA 95201 <br /> f <br />