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Applications Will Be Processed Wh>,ffi�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 carryon busing sin the'ur'sdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) L T1 Address ' <br /> I`_ Owner �« Address. ` <br /> h <br /> J Firm Partners, Addresses and T tep one Numbers W r <br /> aBusiness Telephone No. Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name(Print) Title - Dale <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1.r ❑.PUMPER VEHICLE,PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, " J June 30, 19 Disposal Sites - +� <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. t . CAL. License Renewal No. <br /> Capacity" GaIT,Weights&Measures-No^ <br /> Equipment Parking Address.. <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No..of Vehicles Stored__ <br /> No. of Chemical Toilets Stored � } .rt � '�'�' ��-' ��•_ _ -— .....�. _ �.� ...�._.- ....,, - <br /> 3. ❑ PERCOLATION TEST t <br /> R.S.ror R.C.E. Name R.S.or R.C.E. No. s <br /> Test Location, Test Date/Time - <br /> 4. ❑ SANITATION PERMIT ? © � ,� <br /> Job Add ss/Location t <br /> Owner i A dress <br /> 1:1 SEPTIC TANK 13 CESSPOOL, LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT ' <br /> ❑ PERMANENT © TEMPORARY" C - NEW : REPAIR ❑ OTHER <br /> .5. 0 CHEMICAL TOILETS For July 1, -June 30, 19 x f <br /> Type Construction t f Disposal Site t '' j' 3 <br /> TNo, of Units ) Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ! <br /> Operator Name r Where Certified <br /> ,Plant Location <br /> Plant Capacity i No. Units Served <br /> '"7. ❑ LAUNDRY For July 1, -June 30, 19 - 1 " C <br /> it <br /> -ISlzE. ❑ Lless Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑-DRY CLEANING, Chemicals Used/Amount/Mo. 1 `" <br /> hereby,certify that I have prepared this application and that the work wit#nbe,done.-in-'accordance4with San Joaquin County f r <br /> ordinances, state lawand ru es�hd regulations of th Joaquin Local Weald District. aw <br /> APPLICANT'S SIGNATURE f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY EI PER UNIT 11 PFR SITE C1 EACH 13 January <br /> 1 &Received By January 31 ❑ July 1 &Received By July 31 <br />" REMIT � <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> - DATE - .DATE REMITTED AMOUNT <br /> do _a <br /> 1 FEE -� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �� k <br /> OTHER <br /> s , <br /> OTHER „. <br /> - k <br /> Received by Date Receipt Nm _ Permit No.,,, s Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t 1601 E.HAZELTON.AVE.,'P.O:Sax 2009 STOCKTON,CA 95201 <br /> 'a I <br />