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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 0° <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on busi�ress in the jurisdictional area of the n Joaquin Local Health District <br /> y Business Name (DBA) R � 1S h4 i'Samod Address 1 a� ' <br /> ? Owner AAddress <br /> 9 Firm Partners,Addresses and Telephone Numbers -„- -, <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. — ,. s Date <br /> L Applicants Name (Print) Title <br /> Please check Applicable Category (117)and Fill in the Require 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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location o <br /> Owner,� y �� .d 6 - Address S'�r�e, - <br /> ❑ SEPTIC TANK © CESSPOOL X LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT r. - <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 4 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Locations) !' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - <br /> Operator Name -- Where Certified <br /> , <br /> Plant Location 1 ' <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.'Fl. <br /> ❑ DRYs7 t s�>�g �a )Csalss ryspA/Amo unt/Mp. •� r <br /> mfoN3autna. fartrfythpilnfhnptrforroanrroffhewnl[kfnrwhlollthispQrtnrttslsenpd,tsA?tllnatemploy <br /> E 5iic1#ffict� r$5 1A €piyriirlarfr,�?csf'c�� tlx: &C�iii�r.ia1'#F ty i. <br /> 5»1f c't$i$ )liriii� $G tit' <br /> 010"l71Ciil n�is rd reFttt}a is i 11,.x.'` aMyp4rSOR <br /> 2 fcl.�vf;si�, 1�o-rilfy iha;hi the porfprr,}alrce of the work fpr whlClt this permit i6 igstl8 ,i$hall <br /> AittGiojr rs�tisstti;�ect to, ot;maivs�clilil)iel s I1en)a s Ise I,s llsa ' <br /> n; <br /> s I 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- an-Joaquin L I Hea th District. <br /> APPLICANT'S SIGNATURE X E <br /> FOR DEPARTMENT USE ONLY_ <br /> Fee Is Due: 11ANNUALLY D PER UNIT ,-:D PER SITE ❑ EACH. ❑ January 1 &Received By-January 31 ❑ July 1 &Received By July 31 <br /> _...__.REMIT <br /> 'S BILLING :,REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION pgTE _ 4 DATE REMITTED <br /> AMOUNT <br /> O R ' <br /> C <br /> > FEE � r _ - - <br /> LESS <br /> PRORATION <br /> PLUS 2 �� <br /> PENALTY - � - - <br /> OTHERA <br /> OTHER } ' <br /> i - <br /> ? � � J <br /> Received by Date Receipt No. Permit No. Iss ance Date Mailed Delivered <br /> APPLICANT' RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMITISERVICE5 - '1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA-95201 <br />