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Applications Will Be Processed When Submitted Properly Completed. Be Sure To,Sign Thi Application. <br /> „�. . APPLICATION <br /> (For Non-Transferable, Revocablei'and Suspendable) SEPTAGE ' <br /> ENVIRONMENTAL HEALTH PERMIT ! <br /> LIQUID WASTE <br /> Application is hereby made to carry on bust ss in the jurisdictional area of the..54n Joaquin Local Health District <br /> �gusiness Name (DBA) /0. Address .o i 4r <br /> H11 <br /> z'Owner Address <br /> D,Firm Partners, Addresses and Telephone Numbers <br /> glBusiness Telephone No. y6�` 96Q-7 Emergency Telephone No. " <br /> _J Contractor Licence No. - <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill In the Required In rmation r. ' <br /> 1. © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites. - <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD T <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 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> '41,54 SANITATION PERMIT <br /> Job Address/Location /8 <br /> Owner Address <br /> NO SEPTIC TANK ❑ CESSPOOL 14LEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT <br /> VIPERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER pd t <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> TN <br /> Type Construction Disposal SitePO' <br /> ` <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 R <br /> Operator Name Where Certified. w_ <br /> Plant Location <br /> Plant Capacity - No. Units Served 'r <br /> 7. ❑" LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ la Ical Used/Amount/Mo. <br /> ���It�@11�$�€i#fid#LIr�RH"r#if3@FttiE�#H!{bv�+IRS;"i0firt!{1't€lAf)nt}1e�S�frs�rfiFAllCatl/#it£W4rkf0lWiMlChitl€S erm€tis€ssucd,lsha€inotemptayertYQOrs0�1 <br /> 0 ti h tnEl1!€ter n€a bar 9m�§iipjl! i is l V11,131111 ivas tl r•. r. p I <br /> (lpntrsctgg'y hlrtn €�r t3uh•€€a o j cs �a �lt� �'1 �1+►0�,11vrt;i <br /> Afif f0 J Hti Brit; " t c r ; ` .; N.,.„ , "i r�rti ly that in the.performance of the work for which this permit is issued.I et18€I <br /> Y ptlFSofls t 1 Jo IYpfik!ltri s t£ftijtAt166� n:..z a G ,; ;, f <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an�regu tion oft Joaq I alth District. <br /> APPLICANT'S SIGNATURE X <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE - DATE REMITTED AMOUNT DUE CHECKED <br /> R OU T <br /> FEE .,- lot .. a. - Ra ))) <br /> LESS <br /> PRORATION � <br /> PLUS D <br /> gPENALTY ' <br /> OTHER V' <br /> ;'OTHER - 1 <br /> Received by Date Receipt No. Permit No. Iss nc ate- Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 _ HAZELT VE.,P.O.Box 2009 STOCKTON,CA 96201 <br />