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Applications 1Nii1 Be Processed When Stibmilted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE ,I _ <br /> Application I r�y,{+1ade to oral n s in the jurisdictional area of San Joaquin Local Health District Business Na DBA) B ��`JJ Address 12'65— <br /> Z Owner Il U Address <br /> J Firm Partners, Addresses and Te ephon rpbers�y <br /> IL Emergency Telephone No. <br /> IL Business Telephone No. .. € _ <br /> Contractor Licence No, <br /> L Applicants Name (Print) - Title} Date <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, , <br /> June-3019 �! k Disposal Sites +f <br /> -. � <br /> Motel ❑Other ------ --------------- --------------------- <br /> f hl-,mhPr of hedrogms ------Garhac,�e Grinder---- <br /> - Lot Size ! - -- '�------------ <br /> - ._:. . _ _ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 h <br /> No. of Vehicles Stored � - <br /> P <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name S, R.S. or RFC.E. No. <br /> Test Location IM Test Date/Time "f <br /> 4. (SANITATION PERMIT ® P f4 0 <br /> Job Address/Location �- IVe- <br /> Owner � � _�� .0 Il Address •U4)1 I" 4'&" ' A� <br /> EPT1C TANK ❑ CESSPOOIL �EACHING FIELD ❑ SEEPAGE PIT, ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 0-NEW ❑ REPAIR OTHER :?X/P X12 <br /> 5.Type Construction AL TOILETS For July 1, -June 30, 19 <br /> ' Disposal Site _t.... <br /> No. of Units ii Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I� Where Certified <br /> Plant Location it 4 <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. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t. I <br /> Home owneroriicensedagent'ssigIftirece�tiiicstheiello�ring "Iceriifvth�ttnl.he�Criorm�nCcofti0v?a,4tarw llehiryk� flPfl111 �Ef3��gf,1s� Afl@ietfl�l@l/�41��@f§@it <br /> in such manner as to became subject tc w[1r'r.:�al s Compnn at nr,E;t ni Cafiterr,la. <br /> C mtractor's hiring of sub-ca:ttracting r pinnture cortiticr, Ow. ia119�+ntxt. "I CCT;iiy that in the parinl'mflnu Fi 111G Wflfk tat W1101iil§ @Ef?ll1 si3 f§1?@f ds I§�iall <br /> employ ggr�j�IttJfyoChatzli ia�i� fr ted +ia �SltaBtion and that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws, and rules nd reg tions the San Joaquin Local I ealth Dist 'ct. <br /> !p <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY - <br /> ' E <br /> ' Fee Is Due: ❑ ANNUALLY .i❑ PER UNIT PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> 4 BASE BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 4 EXPLANATION <br /> ,r t' DATE >• DATE-JL REMITTED AMOUNT <br /> FEE <br /> y <br /> LESS - <br /> PRORATION <br /> PLUS I 11 <br /> PENALTY <br /> OTHER II. i r <br /> f OTHER ti e <br /> Received by Date Il Receipt No. Permit No. ' tptp Issuanc ate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES `�!' -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />