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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION G 63- 1?6,- Z� <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE / <br /> r ENVIRONMENTAL HEALTH PERMIT �".7 f <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) 4�1]7 00,yr� Address Re �k°�►-Q�'� A,6z Z,0,0y,�c aw <br /> aOwner r/ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. E Emergency Telephone No. 2-0 <br /> Contractor Licence No. <br /> Applicants Name (Print) Title *�i1��- - - Date f- -d0Z <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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time W <br /> 4. )p SANITATION PERMIT 7i \ <br /> Job Address/Locatio _ <br /> Owner ed-t i-es g. Address - J <br /> K. SEPTIC TANK 11CESSPOOL LEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT s <br /> PERMANENT ❑ TEMPORARY QI NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 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 /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �- ,j -•-�'u Y ( - rev.! <br /> I hereby certify that I have prepared Is application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an regulations of the San Joaquin Local Health District. ��� <br /> APPLICANT'S SIGNATURE X S <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNI ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju{y 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT r� <br /> BASE EXP ANATION PATE DATE REMITTED AMOUNT DUE CHECKE \ <br /> �r AMOUNT Q <br /> FEE T �� <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER 49 <br /> OTHER <br /> A-9- Z_ CD <br /> Received by Date Receipt No. Permit No. IssuanceD Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />