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'Applications Will Be Processed When Submitted Properly Completed:•Be Sure,To-Sign The-Application. <br /> APPLICATION I <br /> (For Non-Transferable;Revocabie,`and Suspendable) SEPTAGE i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE "~ y <br /> Application isherSVy madgto carryon busin ss in the:jurisdictional area of the San Joaquin Local Health District 1 <br /> r Business Name (DBA) D" Address i d <br /> z Owner Address t J <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 6 r(9-,!(0 -7 Emergency Telephone No. i t <br /> IL Business Telephone No. A <br /> a Contractor Licence NO. <br /> LApplicants Name (Print) `Tile w +j +� Date <br /> Please check Applicable Category (1-7) and Fillin the Required Information . t•: .C(y a0 f.I: W't.t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July.iJune.30,.19 — - --Disposal Sites_ <br /> I <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 y <br /> For-July 1, -June 30;-19L <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 /> _ R <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location l' <br /> Owner Address z/ <br /> ❑ SEPTICTANKF ❑ CESSPOOL' &.LEACHING FIELD J. SEEPAGE PIT f; ❑APACKAG' PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ANEW ® REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site r <br /> No. ofUnitsEquipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 F a t r <br /> Operator Name - a Where Certified <br /> Plant Location s= <br /> Plant Capacity No. Units Served <br /> t ' <br /> 7. ❑ .LAUNDRY For July 1, -June 30, 19 - <br /> 'SIZE: t ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. - <br /> -.,�., " m <br /> . - . <br /> ❑ DRY C3 e t g.UgedFy�mount/Mo. <br /> P s f�('9?DoA Inq rmF l lt(Is s$1�1 a 8++; :"!� tf{t�jHA #Pi �lipFiott�l r}p r l}I�rru'nYk farwhl*hla pormit h Ii i►ecl.l shall notemptoyamfQer <br /> 4�< .cl �• � l� RIl!'•�lll�l cj��it¢�t{Il _ <br /> Ft;-r�f tr"cTing €ian tttfr C0rg1 1Q9 thc'i fatl9uriPtl I Gf3rIiE�Ih l lrtrllle pl rfarmanc$bf Iha work for v�hicll this permit is issued,I shall , <br /> r� 4 z F1 exac t'1"P,( tita{s clh} �n fly]1 IyyS`9- i.01+?rrl?€! ,. _ <br /> 7- <br /> I <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, and rules and regulations of the San JOa ]'Local He rict <br /> APPLICANT'S SIGNATURE X t <br /> J y <br /> FOR DEPARTMENT USE ONLY - <br /> Y - <br /> Fee IS Due: 11 ANNUALLY ❑ PER,UNIT ❑ PER SITE ❑,EACH ;❑ January 1 &Received By,January.31 ❑ July 1 &Received By July 31 <br /> m l r BILLING! REMITTANCE r $ REMIT <br /> i <br /> i .BASE EXPLANAAMOUNT DUE CHECKED <br /> TION <br /> _ . DATE AMOUNT <br /> i 8 Zj <br /> FEE' - .. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY- - - - - <br /> OTHER - <br /> p .9 <br /> OTHER <br />' Received by Date Receipt No. Permit No, Is ance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO:' `ENVIRONMENTAL HEALTH-PERMIT/SERVICES-1807 E.HAZELTON AYE.,P.O.Boa 2009'^STOCKTON;CA 95201 . <br />