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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 San,Joaquin,Local Health District.�}-� <br /> y Business Name (DBA) �-_ RaH I LL �1NQF- Address IS LA� C-L <br /> im il\I I��- `A��__� Address <br /> 1 <br /> a Owner L _ _ I <br /> L) Firm Partners, Addresses an Telephone Number <br /> a Business Telephone No. �+� Emergency Telephone No. <br /> Contractor Licence No. J L} D;Nz <br /> L Applicants Name (Print)` �� t✓ \Q A A �-�� Title Date c <br /> ' Please check Applicable Category (1-7)and Fill in the Required Information t <br /> 1. ❑=PUMPER VEHICLE PERMIT:R£GISTRATION (FOR EACH VEHICLE) <br /> For July 1, . June736, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity"'•""'"""'- Ga1.7Weights-&-Measures-No.w` -- <br /> F <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1110 <br /> For July 1, 'JUne-30,-19'. <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored __'_ r - <br /> 3. 1:1PERCOLATION TEST r - (�t/��}I <br /> R.S. or R.C.E. Name • R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT e ► <br /> Job Address/Location % ©U <br /> E, Fl? <br /> Owner Address <br /> SEPTIC TANK [ CESSPOOL LEACHING FIELD SEEPAGE PIT +❑ PACKAGE PLANT t 7 <br /> ❑ PERMANENT ❑ TEMPORARYNEW REPAIR I❑ OTHER <br /> 5. 13CHEMICAL TOILETS For July 1, �J"e 30, 19 ) r <br /> 'Type Construction Disposal Site <br /> No of Units Equipment Storage/Cleaning.Location(s) ' r <br /> (i ❑ PACKAGE TREATMENT PLANT For July 1, -June-30, 19 <br /> Operator Name r Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served _ J <br /> 17.• ❑ LAUNDRY For July 1,, -June 30, 19 �r- <br /> 0 More Than 1,000 S <br /> SIZE: ❑ Less Than 1,000 5q. Ft., q. Ft. <br /> 12-15RY CLEANING, Chemicals Used/Amount/Mo. <br /> r- I hereby certify have prepared this�applicatio and that t e work will be done in accordance with San Joaquin County <br /> E <br /> ordinance tate law ',;a�s ai'1d egulations of !SarnJoa um Local ealth District.APPLICANT'S SIGNATURE X <br /> 77w <br /> FOR DEPARTMENT USE ONLY '"5707%� 1 i I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ; ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 # I <br /> E BASE EXPLANATION BILLNG REMITTANCE '� $ AMOUNT DUE CHECKED r <br /> I DATE DATE f REMITTED AMOUNT <br /> FEE <br /> LESS O <br /> PRORATION <br /> PLUS <br /> 1 PENALTY <br /> i OTHERAy <br /> OTHER <br /> &�_-� -�7-i <br /> IReceived y Date I Recerp-t-No.1 Permit No Issuance Date Mailed Delivered <br /> APPLI ANT-RETURN ALL COPIES TO: F ENVIRONMENTAL HEALTH PERM1T15ERVICES S°� 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />