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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ry APPLICATION <br /> (For Non-Transferable;Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicaticinpis hereby made to rry on business in the jurisdictional area of the SanJ a n cal Health District <br /> BusinessNa a (DBA), I" Address, •. p .9Y, <br /> a Owner 22R,4?la/" :Address <br /> Firm Partners, Addresses and TelephonqN bers <br /> m Business Telephone No. �� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) !' Title r'��s2�y* Date <br /> Please check Applicable Category (1-7)and FIII In the Required Information : <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Irl Vv <br /> For July 1 -- . " June 30, 19-- - Disposal Sites <br /> Description(t4ake/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 Stored4'.�,_ <br /> b 3... E1—PERCOLATION TEST .ter^ 4,.,� _ �_�-' �.• O <br /> R.S. or R.C.E. blame �. L " s R.S. or R.C.E. No. <br /> Test Location25PT St D e/ mi e <br /> 4. 1�-.SANITATION PER , ✓�• r �/ � ,a .. r.. ...s t =" �`. �I1 <br /> Job Address/L catio <br /> Owner M b ii Address <br /> SEPTIC TANK ❑ CESSPOOL 11LEACHING FIELD 11SEEPAGE PIT"0,'PACKAGEs0LANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 <br /> .Type Construction Disposal Site J w <br /> No. of Units _ Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE EATMENT PLANT For July 1, -June 30, 19t� l <br /> Operator Name ' Where Certified ' <br /> Plant Location . f <br /> Plant Capacity �" - ^ti No. Units Served <br /> 7. ❑ LAUNDRY For July`-!"-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 /> * I <br /> ^?..—'--- war-..-"r,a..,,n► e�� k.. `Y � '� r - � . <br /> I hereby certify that I <br /> have pr pared thi application-an that the work will be done in accordance-with San Joaquin County 4• <br /> ordinances, state laws e and ulations of th S Joaquin Local Health District. it <br /> APPLICANT'S SIGNATURE A ) ' <br /> 001, <br /> FOR DEPARTMENT USE ONLY a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT # , <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT i <br /> FEEs <br /> t <br /> ' I a <br /> y <br /> LESS <br /> PRORATION <br /> PLUS <br /> a <br /> PENALTY -- <br /> OTHER <br /> OTHER <br /> a ! 1 67 <br /> Re eW d by JDAle I Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERM&SERVICES' - 1601 E.HAZELTON AM,P. Box 2009 STOCKTON,CA 95201— V <br />