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:.�: Application... <br /> Applications WillBe Processed When Submitted Property Completed. Be Sure o gn e <br /> APPLICATION <br /> (Far Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) Address, <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Tele�phone Numbers _ ? <br /> CL <br /> Business Telephone No. .9 1-U 49 7 Emergency Telephone No.w <br /> Contractor Licence No. 13367. <br /> ` <br /> Title._ Owner. Date 1 <br /> L Applicants Name(Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> K3- <br /> 1. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) { <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. CAL, License No. r <br /> Capacity Gal., Weight s&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30. 19 ti <br /> No. of Vehicles Stored <br /> — - A <br /> No. of Chemical Toilets StoredR R <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name I i <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/ ati n <br /> ner- Address N <br /> SEPTIC TANK CESSPOOL ,WILEACHING FIELD .1 SEEPAGE PIT 11 PACKAGE PLANT <br /> w <br /> ,I{7 PERMANENT ❑ TEMPORARY �{Q:NEW _ <br /> ❑ REPAIR ❑ OTHER C) <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 . 1 t 4 1: : T- <br /> Type Construction i Disposal Site <br /> No. of Units - Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT' For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> t <br /> Plant Location i <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.14 <br /> ; _ ti <br /> A, <br /> 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, a ru and regal sof the San Joa in Local Health District. �, r <br /> APPLICANT'S SIGNATURE <br /> * FOR DEPARTMENT USE O Received By July 31 <br /> Ju4q 1 _ <br /> i <br /> Fee Is'D. ue•-❑,(? NUA <br /> ANLLY ❑ PER UN1T... _ El PER SITE ❑ EACH ❑ January 1 & eceived By January 31 ❑ & <br /> .f. REMIT <br /> '- ~BILLING– REMITTANCE $ AMOUNT DUE CHECKED <br /> 57-- '- BASE EXPLANATION DATE 'DATE -REMITTED - AMOUNT <br /> 7–.ay , <br /> FEE .- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 5 <br /> Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> Received by -,. <br /> ifi01 E.HAZEL70N AVE.,P.O.Box 2009 STOGKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES, �_ . <br />