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Applications Will Be Processed When Submitted Properly Completed. Be Sure'To Sign TheApplication. a <br /> APPLICATION , <br /> (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT •`. <br /> LIQUID WASTE <br /> Applica ion is here�b�y made to carry on business in the jurisdictional area of the San Joaquin Local Health Di trict <br /> H Business Name (DBA) �-Addresses � � ��� <br /> aOwner Address <br /> L) Firm Partners, Addresses and Ttelephone.Numbers <br /> a4 Telephone No T "(e-���� - Emergency Telephone No: <br /> X Contractor Licence No. •' - 3 _ t 8 <br /> LApplicants Name (Print) � �- Date L-4 <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) : ..r w ...�, � A. ^�. <br /> Serial No', CAL. License No.' r CAL. License Renewal No. <br /> Capacity Gal:;Weights &Measures No. <br /> P Y <br /> Equipment.Parking Address <br /> PUMPEWYARD <br /> For July 1, June-30;x;.9 _ i{ <br /> No. of Vehicle Stored _ ` _ ' ' <br /> No. of Chemical,Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E.Name:- ( t f� y' ti R.S. or R.C.E.No. <br /> TestL,oatio'n' , - �, Test Date/Time <br /> � �c _ <br /> 4. SANITATION PERMIT -- w�•�--�-A=r -� -« , <br /> Job Address/location I <br /> Owner _ <br /> t Address _S <br /> F QL.KPTIC TANK ❑ CESSPOOL-4 EACHING FIELD ®"SEEPAGE PIT ❑ PACKAGE PLANT { <br /> MI FVRMANENT ❑ TEMPORARY EI NEW 59.1tEPAIR ❑ OTHER 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site _. "=� '' ; { <br /> No. of Units Equipment Storage/Cleaning Locations).. <br /> 6. ❑ PAC KAGIrTREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name -�" f Where'Certified <br /> t <br /> Plant Location <br /> Plant Capacity * No. Units Served <br /> r �.q <br /> 7. ❑ LAUNDRY For'July, 1 June 30J.9 <br /> SIZE: ❑ Less Than'1,000 Sq.-Ft. ❑ More Than 1,000 Sq. Fl. <br /> micals Used/Amount/Mo. '" <br /> `© DRY CLEANING";Che - r <br /> F l , <br /> t i hereby certify that.I have prepared this applic n an that t <br /> pe work will, be done in accordance with San Joaquin County" <br /> t ordinances, state laws; les'an egulatio th n Jo a uin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 4 <br /> FOR DEPARTMENT.USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PERUN ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> A I "'-- REMIT <br /> BASE EXPLANATION BILLING REMITTANCE f' AMOUNT DUE CHECKED <br /> DATE DATE REMITTED 4. AMOUNT <br /> Y. 14 � <br /> FEE S <br /> LESS <br /> PRORATION -7 !� <br /> PENALTY J��`�y�/ <br /> OTHER <br /> ",.OTHER <br /> M Received by Date Receipt No. Permit No Is ance Date r Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520- - <br />