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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 /> 1licati n ' reby made c r on business in the jurisdictional area of the San JoaquinLocal He Ith DistriWF Business NameA) Address <br /> r, <br /> M Ad ress - <br /> zOwner ... . �;, ... <br /> u Firm Partners, Addresses and Telephone Numbers <br /> IL Emergency Telephone No. �' ' '� 47" -7. <br /> 3 <br /> a Business Telephone No.. <br /> Contractor Licence No- <br /> L Applicants Name (Print) 4 Title — �� �— Date <br /> I <br /> Please check Applicable Category (1-7) and Fill in the Required Information <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 <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 Date/Time <br /> Test Location r: <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Tc ' <br /> Address J "5 �' 1 4* <br /> SEPTIC TANK ❑ CESSPOOLACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW )CREPAiR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Vi <br /> r <br /> Type Construction Disposal Site <br /> t No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location X <br /> Plant Capacity No, Units Served <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 /> HOMO O Aero licensed <br /> e Oaqertfssit-op '-„ e!rorkfer>v#ich!hispermit isissued,lshzflnot employ any perssm <br /> 1 - t r a {• <br /> Conirae.e�'s hi:7:¢g ns '�rn,`I !! <br /> em la erson•, t Ji' ..'r�. "� LC`a;y li}3:!n tli£�Cr#Ci'rn3llC rui the work for vjNeh t!`° i9 i I <br /> j3 y p S l jS +t +J . ,i., l , u, 5 j Ur"lit 55�2d, $h81i <br /> I hereby certify that I have prepared this application and that the-work will be-done in accordance with San Joaquin County <br /> t ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ��� C <br /> t <br /> APPLICANT'S SIGNATURE X <br /> r <br /> - FOR(DEPARTMENT USE ONLY <br /> Fee Is Dile:-.❑—ANNUALL`Y,.,k❑"FER'UNIT; ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 .❑ July 1 8 Received By July 31 <br /> # REMIT <br /> SASE EXPLANATION,,.. BILLING REMITTANCE AMOUNT DUE CHECKED <br /> �- r-- .DATE DATE REMITTED AMOUNT <br /> r <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS , <br /> PENALTY <br /> OTHER _ <br /> - <br /> 1 - < <br /> OTHER <br /> Received by 0 Dater Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES ' 1601 E.HAZELTON AVE.,P.O.Bbx 2009 STOCKTON,CA 95201 <br />