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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) / f <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE =' <br /> Application is hereby m aOp to carry o ri business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Address <br /> z Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. . ' <br /> 4 Contract . Licence No. .: <br /> i <br /> L Applicant`Name (Print) Title ,�-�Pi� J Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> t' 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) } I <br /> For July 1,`. June 30; 19"- Disposal Sites <br /> 'Description, ake/Yr JIG 0i0r) <br /> -. -- <br /> Serial No. .w Fie CAL. License No. CAL. License Renewal No. � <br /> Capy Gal.,Weights &Measures No. t <br /> 11{ <br /> .,Equ)pment Parking Address x' <br /> 2. ❑ PUMPER YARD- <br /> ForJuly1, s � dune 30, 19 <br /> No.;of Vehickll)_To dNo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST s ,. <br /> R.SIor R.C.E.FName A.S. or R.C.E. No. '�ti <br /> Test Location ' _•,..-�" --Tes t Date/Time { <br /> 4. ❑ 'SANITATION PERMIT <br /> Job lAddress/L'ocation ' <br /> Owner Address I• J IOU- <br /> ED <br /> ° - or y <br /> =�'EPTiC TANK ❑ ESSPOOL �YCEACHING FIELD SEEPAGE PIT ❑`Rq`CK-AGE PLANT I <br /> ❑ PERMANENT TEMPORARY ❑ NEW ❑ REPAIR ❑ OTPiFt �c3 <br /> 5. 0 CHEMICAL TOILETS For July 1,-June 30, 19 � <br /> i <br /> Type Construction Disposal Site f <br /> No.1of Units I Equipment Storage/Cleaning Location(s) I r <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 _ <br /> Operator Name t Where Certified <br /> Plant Location ' <br /> Plant Capacity No. Units Served, i <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. `4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> ordinances, state laws, and rules and regal ons oft the San Joaquin Local Health District. ! <br /> APPLICANT'S SIGNATURE X ! <br /> FOR DEPARTMENT USE ONLY y <br /> Fee Is Due: 1:1 ANNUALLY C] PER UNIT 11;VER"SITE—_5 f-FACa,— ❑ January 1 &Received By January 3Tp"- LJ J y;1&'Receiver d B Duly 31 <br /> BILLING REMITTANCE $ li REMIT a <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED f <br /> AMOUNT! . <br /> FEE <br /> -145 <br /> LESS �! <br /> PRORATION ; <br /> PLUS i <br /> PENALTY r <br /> OTHER <br /> -'..,:r.J'''s.tO7HER-�..n.w+.n:- —---- - •..-,+.-A.•.�.�.,-..W..r--.'�--'�",..-.... .-.�.r......-,...-.•-•....�. �.....,.w,w.—.�.-c�..--.��--...,�..��--�_,. <br /> =7a i <br /> 774 <br /> Received by Date s Receipt No. Permi' o. uzince Mailed Delivered - <br /> APPLICANT-RETURN ALL COPIES TO:.r ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1607 E.HAZELTON AYE P.O.Box 20D9 .STOCKTON,CA 95201 ` <br />