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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 /> Application is her y made to carry on business in the jurisdictional area of the Sa_n aquin Local Health District <br /> Add �J �`�Q jG <br /> OF Address �� �I <br /> Business Name (DBA) t <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Q. Business Telephone No. „ Emergency Telephone No. <br /> -J Contractor Licence No. 42 � <br /> Applicants Name (Print)_. ��. �,�1'�GL.i�� Title 9c .Pate-? J s I t <br /> Please check Applicable Category.(1-7)and Fill in the Required Information ~ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <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 /> .,x.. <br /> Capacity Gal.,Weights & Measures No. <br /> 5 <br /> Equipment Parking Address f <br /> 2. 0 PUMPER YARD � 4 <br /> For July 1, � June 30, 19 <br /> No. of Vehicles_Stored T, <br /> No. of Chemical Toilets Stored <br /> _r. 11 1 <br /> 3. E] PERCOLATION TESTS_ <br /> R.S. or R.C.E. Namle �" 4 R.S.or R.C.E. No. <br /> Test Lo tion / `' ( Test Date/Time <br /> 4. 1� SANITATION PERMIT �O ��'T'- - ; <br /> + j <br /> Job Address/Location �r ' <br /> own f '' Address <br /> IG EPTIC TANK ❑ CESSPOOL, CACHING-FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLA i' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW i i J ❑ REPAIR ❑ OTHER <br /> 5. 1:1 CHEMICAL TOILETS For Juky 1, -June 30, 19 ' <br /> Type Construction � -z 13i9p'-al Site <br /> No. of Units 64 Etluipment,StdFade7Cleaning Location(s) 4` <br /> 1�t - d <br /> 6. ❑ PACKAGE TREATMENT PLANT.;.,For July 1, -June 30, 19 �- <br /> Operator Name I t Where Certified <br /> Plarit Location <br /> No. Units Served <br /> Plant Capacity l ll r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 F 1 <br /> ` I ❑ More Than 1,000 S Ft. ' <br /> SIZE: ❑ Less-Than 1,000 Sq. Ft.,, _ q <br /> ❑ DRY CLEANING,-themicals Used/Amount/Mo. , <br /> I hereby certify that I have prepared this'� pplication-and-that the:vvorkviH_be done in accordan a w�Ith San Joaquin County <br /> ordinances, state laws, and rules and re patio en ' rquin Local_Health District. { <br /> APPLICANT'S SIGNATURE X_ ! / ` f <br /> FOR DEPARTMENT USE ONLY <br /> _ <br /> �I <br /> F ee IS"DUe: ❑.,AF4AUAL-LY _0 PERrUIVIT 0 PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 ❑ July 1 &Received-By July 31 <br /> - , REMIT'- I <br /> BILLING REMITTANCE $ AMOUNT DUErCHEEKEO <br /> BASE EXPLANATION REMITTED i <br /> r� <br /> DATE-, �i�•- � OATS AMDUNT <br /> FEE �... <br /> LESS <br /> PRORATION _ <br /> PLUS - <br /> PENALTY s <br /> !OTHER <br /> OTHER ,.:, <br /> Received by Date fieceipt No Permit No. ,::,;;su -:�, Iss ance ate ; -Mailed ,Delivered <br />#!, APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES `1601 E.HAZEL TON AVE. P.O.Box 2009 STQCKTON,GA 95201 <br /> x J <br /> , <br />