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Applications Will Be Processed When Submitted Properly Completed. BeSure <br /> APPLICATION <br /> (For Non-Transferable,Revocable',-'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _ <br /> LIQUID WASTE <br /> Appl icatio ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Distr�� <br /> G'P'V G u c, Address; S�p cz <br /> Business Name (DBA) <br /> -Address y - <br /> a Owner <br /> 0 Firm Partners, Addresses and Telephone Numbers -�*Iw Emergency Telephone No. <br /> CL Business.-Telephone-No., <br /> Contractor Licence No. Date <br /> Tltle <br /> Applicants Name (Print) <br /> Please check Applicable.Categary,(1 7)and Fill In the Requiredlntormation nr4. <br /> j 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />�( For July 1, - <br /> June 30,'19:—' Disposal Sites <br /> Description(Make/Yr., Color_) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity <br /> Gal.,Weights &Measures No'.- <br /> - <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.No. <br /> R.S.or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMITO /p'1, <br /> Job Address/Location p f� f'✓ l✓ `�C <br /> ' Owner <br /> iC .9 . lJd!rO Address ❑ PACKAGE PLANT " <br /> SEPTIC TANK ❑ CESSPOOL ; LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> 11 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> x Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified x <br /> Operator Name <br /> t Plant Location <br /> No. Units Served <br /> Plant Capacity ,. <br /> 7. 11LAUNDRY For July 1,-June 30, 19- <br /> SIZE_ 1:1 Less Than 1,000 Sq.Ft."0.13 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals'Osed/Amount/Mo. 41^ <br /> k Flomeownarorlican edagPnYssiq:;axurc+r.�rtiti�sthe4oflo:+mg "Icertify thilir,ghr,Del Sort;lance0lhe%vorkferthhichthis perm itisis5aetl,'St oternployanyper'- <br /> m. suh rt to wotkm n :Ia,.in.;+a�as #t%lfiinni: , r r ed,!shad <br /> in such manner as to ber,a ie arcs rrm e L �� t <br /> Contractor's.+4irin_� et sui;-cast?�Gi;rt�a st��^1�aa :^r�if��:, ,+^. nS3©v?�i:1� 1C :;iiyf}£_ii3i=•Z> ¢er`6rillar�., l?I�e I; 4r�"+t�irhti.ipe <br /> employ pKsons siiL-jent IR Wort mz n b vvii!1F.n'iaits'll l;?4!a:!i�ni ij',t.'i." s <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,slate laws, and rules and regulations of the San.Jaaquin Local Health District. <br /> -APPLICANT'S SIGNATURE X ; <br /> FOR DEPARTMENT USE ONLY -r <br /> Fee IS Due: C1 ANNUALLY PER UNIT 11PER SITE ❑ EACH ❑ January 1 &Received By January 31 . ❑ July 1 &ReceiveRdEMIT By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION pATE DATE .. REMITTED AMOUNT <br /> FEE- <br /> LESS <br /> EE LES5 - <br /> PRORATION <br /> PLUS' } <br /> PENALTY <br /> OTHER <br /> c OTHER, _ <br /> r <br /> Received h Dat Receipt No. Issuance Date Mailed Delivered <br /> Perm;[No. <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 0 <br />