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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> F (For Non-Transferable, Revocable,•and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTKPERMIT <br /> LIQUID WASTE <br /> Application is herebyjnade to c rryn business In the jurisdictional area of th_a San Joaquin Lo ai Health Dist is <br /> F Business Name {DBA)�! z n�� Address 1 <br /> a Owner_0_,-A1,'r6 e. L <br /> __ •_ Z� _ Add ess <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No, <br /> Contractor Licence No. _ t <br /> Applicants Name (Print) Title444"U`i Date. .%� e2— ) <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 /> IJ 2. ❑ PUMPER YARD <br /> r -For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> ,No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Y <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANIUTION-PERMIT-�-�-*" <br /> .Job Addresskocation <br /> Owner dklez Address T a d G' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELQ ❑ SEEPAGE PIT C1PACKAGE PLANT <br /> ❑ PERMAN6T ❑ TEM_PORARY O'NEW 1:1REPAIR , C] OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction I Disposal Site �. <br /> No. of Units Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACK''i4GE TREATMENT PLANT For July 1, -June 30, 19 z <br /> Operator Name _.Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> r 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />" ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> j F <br /> ` 01046, �ieq+'a ii�lo eFif fi rtiistvaluaeiegp;'9CWZ'IRitintheWformiiiT£eoftll wgrkforllq&bthis ersnitisisatted,#shaHtfotdtlpfayar►Ypersan <br /> _ 5N11j towarkniadst&no nSatlon+awsot ornia," I <br /> Rj t 1'. . or'wb`contiaetwra sip tion la a of Call tfb4 I uerti i Iterfefrnae�at tha work#or wE�+ch lhls nrrit is issued,l shah <br /> 40`_ <br /> `er►tl3lal�pits subject to wprktRari s cgrnpcttsatioa I�srs e#Ca+lfornis 'Y �t <br /> I Hereby certify that I have prepar' this application and that, the work w ill be done in accordance with San Joaquin County <br /> ordinances, state laws, and ruleS and regulatlorls of the an Jaquin Locdl Health District. <br /> APPLICANT'S SIGNATURE X <br /> a <br /> ted_ <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1,&Received By January 311 ❑ July 1 &Received By July 31 <br /> REMIT <br />{ BASE EXPLANATION BILLI G REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE y DATE- REMITTED II <br /> AMOUNT 1` <br /> FEE LQ$ <br /> LESS 1 I� <br /> PRORATION r <br /> PLUS. I <br /> PENALTY.- A #...� <br /> 1 <br /> OTHER .. f <br /> OTHER <br /> I� Rec ived by r - LlEkte Receipt No. Permit Nd. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />