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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. -9 v <br /> APPLICATION <br /> (For Non-Transferable,'Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTEF <br /> Appl ication is hereby made to carry on bess in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) usin —Address <br /> z Owner Address <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 'y O Emergency Telephone No. <br /> Contractor Licence No. — '!7 <br /> LAPPlicants Name (Print) ` Title Date —//—IF Z-. <br /> Please check Applicable Category (1-7) and Fill in the Re ulred Information ,A _ /� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) {/li <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. r 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. <br /> EST -R.S. or R.C.E. Name R.S. or R.C.E. NO. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT' <br /> i Job Address/Location 2 <br /> Owner S' 63- .o Address s � <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT . ❑ TEMPORARY ❑ NEW Of REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 `` <br /> Type Construction Disposal Site I <br /> No. of Units: Equipment.Storage/Cleaning Locations) ' <br /> t fi. 1-1 PACKAGE TREATMENT PLANT For July 1, -June 30"19—+ - �� $Wh + <br /> Operator Name - -.,-:Where-Certif led— <br /> �- <br /> Plant Location __ ddF <br /> Plant Capacity No. Units Served M <br /> 7. ❑ LAUNDRY- For July 1, -June 30,.19 y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY Ica s Used/Amount/Mo. <br /> su �egertl' signnlererercft�sih«inStc�x;�,�: lre ifythatinthencrormanc^a!thework,loriihilhthis permit 36ISSUM,I0allnot mployPfiyp6rron <br /> �s iht orae sr�t�jecl to tvorkffiaifs colnp�u�til i117 rs a1%aliforitia.' <br /> !> !+§�sr'31 ih#FtF� tyf 41vt brrh�ezina ss nanit star; cs 1°�: .1v:�i 1 '! ccYi(y <br /> It'at in the performance of the work for which thf$pormit f�fs�Ue�,j hilt <br /> `1 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 Joaqui oval Health District. F <br /> APPLICANT'S SIGNATURE X <br /> i -t- — t <br /> FOR DEPARTMENT USE ONLY �, # <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE 5 g REMIT <br /> v BASE EXPLANATION e.-DATE :�"^ y' « DAtE-- -REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE —LIS. a <br /> r <br /> LESS <br /> PRORATION s <br /> PLUS <br /> PENALTY' 1. . <br /> OTHER <br /> OTHER �µw <br /> Received by Date i Receipt No. Permit No. 1 uan a Date Maul6d rDelivered <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201=�•��-' <br />