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Applications Will Be Processed When Submitted Properly omp e e p ) '� A- <br /> APPLICATION '-- <br /> (For Non-Transferable, Revocable,and Sus endable �'x SEPTAGE � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> J tY f LIQUID WASTE n <br /> Applicatio 15 hereby made'to marry on bysins in the jurisdictional area of the Sa Joaquin Local Health District <br /> Address t, <br /> sri Business Name (DBA) r s <br /> Address <br /> aOwner <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> ..a Business Telephone No. <br /> Z3 d13 <br /> Contractor Licence No. Title Date ) <br /> L Applicants Name (Print) �j, <br /> 1-7 and Fill in the Required Information rig,;, Vb <br /> Please check Applicable Category( ) <br />{ 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> 1 June 30, 19 Disposal Sites <br /> ly <br /> For Ju - <br /> Description(Make/Yr., Color) CAL.-License Renewal No. <br /> CAL. License No. <br /> Serial No. <br /> Capacity Gal.,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 y <br /> 3. ❑ PERCOLATION TEST R.S.or R.G.E. No. <br /> R.S. or R.C.E. Name Test Date/Time - <br /> Test Location ; <br /> i 4. ❑ SANITATION PERMIT <br /> ..... <br /> Job Address/Location Address Owner NG FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ® LEACHING <br /> SEPTIC TANK 11 CESSPOOL ❑ REPAIR ❑ OTHER Ntft; � W� <br /> JI PERMANENT ❑ TEMPORARY NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 1Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> F { <br /> g. 11 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified, <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> .SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> =I'llC'7�iHi 0 i"0wp`-�INl�i�N 4�rl�tSY19 1 117iS1411I permit Is 3a�tI19191PJ11pSG';25�� fiSL`'- <br /> f st} �1{ cn,�a}gr §tq b-4 0,stilalaet iq yioik a§6fl�ffil �asat 9{p d,ff $ t QC 3f9/n3a:' <br /> r S �iI+R�-or -� c accinq s� r wr �srtifi s :; following; „!S�riiiy S'lzat l�fa�e per�l7rrl�alc:oi ifit wcrk inr uihiCi3 this permit is issued,f silat; <br /> ��oY�rs9�?§�p>�;�uA�* ��r.4a��e,�sas,�n ila�rs 9f�CA9sisrsiiar. , <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joa Lo I Health District. y <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS DUB: [I ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re ived nuary 31 Juiy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE - AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE IT D AMOUNT <br /> FEE c <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER f <br /> OTHER r <br /> Receipt No. Permit No. Issuance Da e <br /> eceivo by Date 1601 E.HAZELTON AVE.,�P.O.Box 2009 STOCKTON,CA 95201.. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />