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r 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 /> Applicatio 's hereby made to on business in the jurisdictional area of the San/Joaquin Local ealth District orf <br /> Business Name {DBA) 'Address 07 / z• <br /> P_ Owner C e Address S4^-( - <br /> a <br /> Firm Partners, Addresses and Telephone Num ers 'S L--3-- '5 r=, <br /> aBusiness Telephone No. 2►�� �� Emergency Telephone No. q <br /> t Contractor Licence No. '� _ <br /> LApplicants Name {Print) �' r— �-G7 Title — Date — G <br /> Please check Applicable Category (1-7) and Fill in the Required 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 /> i R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> I 4. ❑ SANITATION PERM,ICZ,,, <br /> Job Address/Locatio <br /> Owner as N mai.! _ We-, ZO Te#4 ZZHAddress <br /> ElSEPTIC TANK C1 CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> /9a�1 �� <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 -�� i� �"w Z ,a 1�! <br /> C Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZES ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 5 <br /> I 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 r 69s and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r 'p O -- <br /> -4 I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juty 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE. CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> r� ,�x� « <br /> FEE `.+I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t _ tet. �, <br /> + Recei�y ' Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> �; APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.'HAZELTON AVE.,P.O.ao'x 2009 STOCKTON,CA 95201 _ <br />