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_.. .. <br /> Applications Will Be Processed When Submitted Properly Completed. tiebure Ioolull 1 <br /> � <br />�/ -- APPLICATION <br /> a. <br /> (For Non-Transferable,Revocable,and Suspendabte) SEPTAGE <br /> y ENVIRONMENT AL HEALTH PERMIT <br /> LlQU.ID WASTE <br /> *, I <br /> Application' ereby m e to rry business in a jurisdictional area of th J uin Local Health Dis r ct. <br /> Address <br /> mBusiness Name (DBA) Address i Al <br /> z Owner <br /> 4 <br /> I Firm Partners, Addresses and Telephone umbersoor Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Date L <br /> Title <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required information <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. , <br /> Gal.,Weights &Measures No. <br /> Capacity 1` <br /> Equipment Parking Address <br /> 2. 0 PUMPER YARD ? <br /> � t <br /> For July 1, June 30, 19 f <br /> No. of Vehicles Stored _ ri <br /> �# ri <br /> No. of Chemical Toilets Stored <br /> r 't t �" �p <br /> 3. ❑ PERCOLATION TEST x , R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name i <br /> I Test Date/Time <br /> Tes cation � /I r q . ..t <br /> �i 4. SANITATION PERMIT— ""�7" "',Q �J J v� <br /> Job Ad ss/Luca 'ongddress <br /> O ner 13 PACKAGE PLANT <br /> SEPTIC TANK CESSPOOL LEACHING FIELD VSEEPACE PIT 13OTHER <br /> PERMANENT ❑ TEMPORARY NEW 13REPA_1Rk cc/• <br /> 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> 4 Disposal Site ` <br /> ` )% Equipment Storage/Cleaning Location(s) <br /> No.of'6nits <br /> B. 0 PACKAGE.TREATMENT PLANT For July 1, -June 30, 19 j Where Certified: <br /> ' Operator Name <br /> Plant Location "R <br /> rNo. Units Served <br /> . <br /> Plant Capacity <br /> 7.' ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE' 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> '0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t Barr►eawnesorEicenseda srst'ssign�taracet:ifestflefclloa�-�a; lr rtifvfl1 ?i, LhaperarrtsancEnith��^.rvAfCrwhkch this permit 15issuedl,Is,h-_!'t!aferr;.n;n;f!nyPC' <br /> in such manner as to becorna subiCGt to,.'crKman's c r:ll,a:;saiinn#aex's f r'af'en,; <br /> r .f� 4 tf, ��, ur ? r ii i�1s.5'J ,I Sn4:! <br /> r t c �' Lure Cr3:t:wiC :ire tdY 'k,iiC:' "L'e't V that ill �"pg�i�"�21>:;�'L. ,:E E'irl\'or whir, hi$prrrE;r � <br /> Contractors Nina or sub-c�,�r Gti>5� gi sa �- _�` <br /> CIripID�pEi•SCNI3SE;�iect to ic!1:man'S of Ca.i fminiu.' <br /> 1 hereby certify) that i have prepared this application and that the workiwill be done in accordance with San Joaquin County <br /> ' ordinances, state taws, an rules and regu tions.Ot:. ` an Joaquin Local Health D.istriGt.' <br /> APPLICANT'S SIGNATURE X <br /> IA <br /> �J FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July t &Receiv REMIT <br /> d By uIy 31 <br /> •BILL'ING y `� REMITTANCE $ AMOUNT DUE CHECKED <br /> ,B SE f EXPLANATIONai DATE REMITTED AMOUNT <br /> –'DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER J <br /> __ Pert No lssuan a flats aMaited 20o9 STOCKTON,CA 95201 <br /> Deli ered <br /> Receipt Nv.. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> Received by Date 1601 E.HAZELTON AVE.,P.Q.Sox <br />